Failure to Document Notification of Change in Condition
Penalty
Summary
The facility failed to document the notification of the resident or resident representative for a change in condition for two residents. For Resident #53, the medical record showed no evidence of a Change in Condition Evaluation being completed, nor was there documentation of notifying the resident's representative or emergency contact. The resident was transferred to the hospital due to unstable vitals, but there was no record of the resident leaving for a physician's visit or with whom. The Licensed Practical Nurse (LPN) acknowledged that the resident's wife was present but did not document the change in condition evaluation. Similarly, for Resident #488, the facility did not document notifying the family or representative about the resident's change in condition. The resident was observed to be sluggish with fluctuating oxygen saturation levels, leading to a transfer to the emergency room. The Change in Condition Evaluation section for notifying the family or representative was left blank. The LPN stated that the resident's daughter was present during the change in condition but admitted to not documenting her presence or awareness of the situation.
Plan Of Correction
F580 NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #53, there was no change of condition completed, no notification to family, no documentation as to where or with whom the resident left. Nursing staff will be in-serviced to complete a change of condition for resident when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. 2) In the allegation of Resident #488, there was No documentation notification made letting emergency contact/guardian know the resident went to the ER. Nursing staff will be in-serviced to complete a change of condition for resident when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: In-service Nursing staff to complete a change of condition for residents when being discharged to the hospital, to notify and document the residents emergency contact/guardian when being sent to the hospital, document to where the resident went and with whom. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: