Failure to Promptly Notify Family and Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide timely notification to a resident's family and physician following a significant change in the resident's condition. According to the facility's policy, when a resident experiences a change in condition, the physician and family or responsible party must be notified promptly. In this case, a resident with a diagnosis of diffuse traumatic brain injury, who was bedbound, non-communicative, and had severe cognitive impairment, was found unresponsive and not breathing late at night. CPR was initiated, and emergency medical services (EMS) were called. Despite these critical events, the family and physician were not notified immediately. Documentation and staff interviews revealed that after the resident was found unresponsive and CPR was started, multiple attempts were made to contact the Medical Director and Director of Nursing, but there was no immediate response. The resident was not pronounced deceased until several hours later, and only then was the family notified. Staff confirmed that the family was not informed of the change in condition or the initiation of CPR until after the resident was officially pronounced deceased. The facility's policy required prompt notification, but this was not followed. The family member interviewed expressed distress and confusion about not being informed sooner, learning of the resident's death only hours after the event. Staff interviews further confirmed that the family was not notified during the critical period when the resident was unresponsive and resuscitation efforts were underway. The delay in notification was attributed by staff to the fact that the resident had not yet been pronounced deceased, despite the clear change in condition and initiation of emergency interventions.