Failure to Notify Responsible Parties and Urologist of Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident about changes in diet consistencies and failed to inform a urologist about symptoms of a urinary tract infection (UTI) for two residents. Resident 10, who was cognitively intact and dependent on staff for care needs, experienced a choking incident on water during medication administration. As a result, the resident's diet was downgraded from thin liquids to nectar thick liquids. Despite this significant change, there was no documented evidence that the resident's responsible party was informed about the downgrade in diet consistency after the incident or following a speech therapy assessment. Resident 22, who was also cognitively intact and had an indwelling urinary catheter, was under a urology consult that required notification of the urologist if UTI symptoms developed. The resident exhibited symptoms such as lower back pain and urinary frequency, leading to the reinsertion of the foley catheter. However, there was no documented evidence that the urologist was notified about these symptoms. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure in communication and notification protocols.