Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a significant change in the resident's condition. The resident, who had diagnoses including Parkinson's disease and dementia, exhibited signs of a change in condition on February 1, 2025. A nurse noted that the resident was not acting like herself, had difficulty grasping a cup, and was unresponsive to questions. Later, the resident was unable to eat supper, chew, or swallow without encouragement, prompting the nurse to order a speech therapy screen. Despite these observations, there was no evidence that the physician or responsible party were notified of the resident's condition change until the following day, February 2, 2025, when the resident's family alerted the nurse to the change in mental status. The nurse then documented that the resident was alert but unresponsive, unable to move her arms or legs, and nonverbal. The physician was finally notified and instructed the staff to send the resident to the hospital for evaluation. The Director of Nursing confirmed that the responsible party and physician should have been notified earlier.
Plan Of Correction
1. Resident 1's provider and family notified. Meeting with RP was held and status updates provided. 2. Reviewed all residents who were transferred to hospital in last 30 days for notification of RP and provider. 3. Re-educate licensed nurses on the importance of promptly notifying the physician and responsible party regarding any significant change in a resident's condition. 4. Perform weekly audits for the next four weeks of residents transferred out of facility with changes in condition to ensure compliance with notification procedures. 5. DON/designee will report audit findings at next 2 QAPIs for review and recommendations.