Failure to Notify State Guardian After Resident Choking Incident
Penalty
Summary
The facility failed to notify a resident's state guardian following a significant change in the resident's condition. The resident, who has a history of dementia, schizoaffective disorder, and major depressive disorder, experienced a choking episode during dinner. The nurse on duty responded by performing the Heimlich maneuver, clearing the airway obstruction, and administering supplemental oxygen when the resident's oxygen saturation dropped to 89-90%. The resident's condition stabilized after intervention, and the provider was notified, but there was no documentation that the state guardian was informed of the incident or the change in oxygen saturation within 24 hours. Interview with the nurse involved revealed that he was unaware the resident had a state guardian and therefore did not notify the guardian after the incident. The Director of Nursing confirmed that facility policy requires notification of the resident's physician and representative or guardian in the event of a change in condition or incident. The resident's guardianship documentation also specifies that the public guardian must be notified immediately of incidents or changes in condition. Despite these requirements, the guardian was not informed as required.