Failure to Timely Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to timely notify a resident's representative of significant changes in the resident's condition, including a fall, the need for medical imaging, new pain medication orders, and a diagnostic imaging appointment. According to the facility's policy, the responsible party must be notified of any change in the resident's condition, and all attempts to reach the physician and responsible party should be documented, including the time and response. However, documentation and interviews revealed that the resident's representative was not promptly informed of these events. The resident involved was an 89-year-old with multiple diagnoses, including atrial fibrillation, heart failure, a history of TIA, and cognitive communication deficits. The resident had moderate cognitive impairment and was dependent on her representative for communication regarding her care. The representative was listed as the first emergency contact, and there was no power of attorney on file. Despite this, the facility attempted to contact the resident's deceased daughter, who was not listed as a contact, and failed to notify the actual representative in a timely manner. Progress notes indicated that the fall occurred late at night, and while there were attempts to notify a family member, these were directed to the wrong individual. The resident's representative was not informed of the fall, the Xray, or the new pain medication orders until approximately 17 hours after the incident, and only after he inquired about the resident's condition. Staff interviews confirmed that the expectation was to notify the responsible party after a fall, but this did not occur as required by facility policy.