Failure to Notify Family of Resident's Condition Change
Penalty
Summary
Platinum Ridge Center for Rehab and Healing was found to be non-compliant with federal and state regulations regarding the notification of changes in a resident's condition. The facility failed to promptly inform the family of a significant change in the medical condition of a resident, identified as Resident CR1. The resident, who had a history of cerebral infarction, ileostomy, and aphasia, experienced a change in condition when blood was noted in their colostomy bag. This incident required a change in medication, specifically a reduction in the dosage of Eliquis, a blood thinner. The facility's policy mandates that the physician and resident representative be notified within 24 hours of any significant change in a resident's condition. However, in this case, the resident's responsible party was not informed of the change in condition or the medication adjustment until 36 days after the event. This delay in communication was confirmed through a review of clinical records and staff interviews, including an admission by the Director of Nursing that the notification was not timely. The deficiency was further highlighted by a concern raised by the resident's representative, who reported not receiving updates about the resident's condition or medication changes. Interviews with staff, including an LPN and the Director of Nursing, corroborated the failure to adhere to the notification policy. This lapse in communication violated the resident's rights and the facility's responsibility to keep family members informed of significant changes in the resident's health status.
Plan Of Correction
There were no adverse effects or harm to resident CR1. CR1 has been discharged from the facility. The Director of Nursing (DON) / Designee will educate the nursing staff on notifying the resident, resident's physician, and resident representative when there is an injury, decline, transfer, discharge, room change, or medication change. DON / designee will perform audits daily x2 weeks, 3x a week for 1 week, and then 2x a week for one week. To ensure that notification of injury, decline, transfer, discharge, room change, and medication changes are being completed. This plan of correction will be monitored in daily clinical meetings and monthly Quality Assurance Meetings until facility compliance is met.