Failure to Notify of Changes in Resident Condition
Penalty
Summary
The facility failed to notify resident representatives and/or medical providers of changes in condition for two residents, leading to a deficiency. Resident R62, who had a BIMS score of 5 indicating severe cognitive impairment, experienced significant health changes, including bright red blood in a brief and multiple instances of emesis. Despite these changes, there was no documentation of communication with the resident's representative or medical provider, as confirmed by the Director of Nursing. Resident R29, admitted with severe cognitive impairment and various diagnoses, was diagnosed with Trichomoniasis during a routine gynecological exam. The resident's guardian was not informed of this diagnosis or the subsequent start of antibiotic treatment. The guardian only became aware of the situation during a phone interview, indicating a lack of communication from the facility. The deficiency was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged the failure to notify the appropriate parties of the changes in condition for these two residents. This lack of communication is a violation of the facility's policy and federal regulations, as it failed to ensure that resident representatives and medical providers were informed of significant changes in the residents' health status.
Plan Of Correction
1. The concerns identified for R29 and R62 cannot be retroactively corrected. The facility will ensure that the physician and the resident representatives are immediately notified of the residents' changes in condition. 2. The Director of Nursing (DON)/Designee will review that notifications have been made and documented in the residents' medical records during clinical morning meeting. Ensure that all nursing staff are aware of the facility's policies regarding the reporting of changes in residents' conditions. This includes understanding what constitutes a significant change and the protocol for communicating this information. 3. The Director of Nursing/Designee will conduct retraining sessions for all nursing staff on the facility's policies regarding the notification of changes in resident conditions to physicians and resident representatives. 4. Updated protocols will be approved by the facility's governing body and incorporated into the staff training manual. 5. The Director of Nursing/Designee will implement a weekly audit for the next two weeks then monthly for two months to ensure compliance with the notification protocols. The audit will specifically check for timely documentation and notification of any changes in resident conditions. 6. Audit results will be documented and reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings.