Failure to Notify Resident's Representative of Changes
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition in a timely manner. Specifically, the resident, who had multiple diagnoses including multiple sclerosis, Alzheimer's disease, neuromuscular dysfunction of the bladder, and muscle weakness, experienced a change in condition when their suprapubic catheter was leaking and not draining into the Foley bag, accompanied by abdominal pain. The physician was notified, and the resident was sent to the emergency room for evaluation. However, there was no evidence that the resident's representative was informed of this transfer to the hospital. Additionally, the facility did not notify the resident's representative of a new physician's order for Citalopram Hydrobromide, a medication used to treat depression and regulate mood and behavior. The lack of notification was confirmed during an interview with the Regional Clinical Consultant, who acknowledged that the resident's representative should have been informed of both the hospital transfer and the new medication order. This oversight was identified as a deficiency in the facility's compliance with the requirement to notify resident representatives of significant changes in the resident's condition.
Plan Of Correction
Resident # 51 responsible party was notified by the Director of Nursing or designee. Residents were reviewed for the last 30 days for change in condition, change in orders, and/or transfer to ensure resident and/or responsible party were notified by the Director of Nursing/designee. Licensed staff will be educated on timely notification of change in condition, change in orders, and transfer of resident to resident and/or resident representative and notifying appropriately by the Director of Nursing/designee. An audit will be conducted for those residents that have a change in orders or transfer to the hospital to ensure resident and/or resident representatives are notified timely of change in orders or transfer to hospital 5 times a week for 4 weeks, then weekly for 4 weeks, and then ongoing by the Director of Nursing/designee. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.