Failure to Notify Resident's Representative of Hospital Transfer and Medication Changes
Penalty
Summary
The facility failed to ensure proper notification of a resident's representative regarding significant changes in the resident's condition and treatment. Specifically, the facility did not inform the resident's representative about the resident's transfer to the hospital on November 9, 2024, after the resident exhibited altered behavior and was diagnosed with status epilepticus. Additionally, there was no documented evidence that the resident or their representative was notified about changes in medication orders, including the administration of Keppra and Pantoprazole, on November 24 and November 26, 2024, respectively. The resident in question had moderate cognitive impairment and required assistance with daily care needs, with diagnoses including epilepsy and a gastrointestinal stromal tumor. The Director of Nursing confirmed that the notifications were not made, which is a violation of the facility's policy on residents' rights. This policy mandates immediate notification of the resident, consultation with the resident's physician, and notification of the resident's representative when there is a significant alteration in treatment or a decision to transfer the resident from the facility.
Plan Of Correction
1. Resident 1 was notified of changes, and it was documented in point click care which is an electronic medical record keeping system utilized by the nursing home. 2. Education to licensed staff including agency to be completed on notification and documentation. 3. Audits will be conducted daily X 5, then weekly X 4 until compliance is met. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.