Failure to Notify Resident Representatives and Providers of Changes
Penalty
Summary
The facility failed to comply with the requirements for notifying resident representatives and medical providers of changes in medication or condition for three residents. Resident R10, who had a BIMS score indicating severe cognitive impairment, was prescribed Eliquis, an anticoagulant medication, but there was no documentation of communication to the resident's healthcare power of attorney about this new medication order. This lack of communication could have impacted the resident's care and decision-making process. Resident R11, with a BIMS score indicating moderate cognitive impairment, experienced a significant change in condition, including nausea, vomiting, and low food consumption. Despite these changes, there was no documentation of communication to the resident's spouse, who was the healthcare decision maker, about the initiation of intravenous fluids or the resident's refusal of meals. Additionally, there was no evidence of communication with the medical provider regarding the resident's symptoms or the need for treatment for nausea and vomiting. Resident R2, with a BIMS score indicating severe cognitive impairment, experienced a significant change in condition when found unresponsive and later transported to the hospital. The facility failed to document notification to the resident's daughter, who was the responsible party and power of attorney, about the change in condition and the hospital transfer. The lack of documentation and communication in these cases highlights the facility's failure to adhere to the notification requirements, potentially affecting the residents' care and safety.
Plan Of Correction
The responsible parties for Residents R10, R11, and R2 were contacted immediately upon identification of the deficiency to provide retrospective notification and updates on the resident's condition and treatment. The attending physicians and providers were also notified where clinical follow-up was necessary. Progress notes were updated to reflect the communications and any interventions completed post-notification. The DON/designee conducted a house audit for new medication orders, changes in condition, and transfers to the hospital, from 3/31-4/21, and validated documentation of notification to the physician and resident representative. The DON/designee will provide education to licensed nurses to ensure notifications must occur for residents with change in condition, new treatment orders, and transfers out to the hospital by 4/30/25. The Director of Nursing (DON) or designee will perform an audit on the following: new medication orders, changes in condition, transfer to hospital, and documentation of notification to the physician and resident representative; 5 days per week for 4 weeks, then 3 days per week for 2 weeks.