Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in care or condition for one of the residents reviewed for notification of change. This deficiency involved a resident with a history of Huntington's disease, dementia, and adult failure to thrive, who was found to have an open area on the right ankle and was diagnosed with localized edema. Despite these changes in the resident's condition, the family member and Durable Power of Attorney (DPOA) reported not being informed by the facility since the resident's admission. The family member expressed frustration over the lack of communication, stating that she only became aware of the resident's new health issues when she inquired with the resident's nurse during a visit to the facility. The Director of Nursing confirmed that it is the facility's policy to inform a resident's DPOA of any acute changes in health, which was not adhered to in this case.
Plan Of Correction
Element 1: Resident #102 resides in the facility and has a FM / DPOA who was notified of resident's condition on 3/17/2025. Element 2: All residents reviewed in Clinical stand-up meeting on 3/19/25 to identify any change of condition in real time. DPOA notified of any changes identified. Element 3: All Nursing staff will be re-educated by the QAPI Development Coordinator on the Change in Condition policy by 3/24/2025. Any staff member that has not been re-educated by 3/24/2025 will be removed from the schedule until re-education is completed. Element 4: DON / designee will review the clinical dashboard daily, Monday-Friday to identify changes of condition and ensure notifications are completed appropriately. The Director of Nursing is responsible for achieving and maintaining compliance.