Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's representative following a significant change in the resident's condition and a change in the treatment plan. The resident, who had multiple diagnoses including stage 4 kidney disease, diabetes, hypertension, atrial fibrillation, and cellulitis, experienced acute shortness of breath with an oxygen saturation of 68%. The nurse administered oxygen and a nebulizer treatment, and the physician was notified, who then ordered labs and a chest x-ray. However, documentation showed that the resident's representative was not informed of these changes until nearly two days later, despite the initiation of new treatments and diagnostic procedures. The delay in notification was confirmed through medical record review, which indicated that the representative was only contacted after the representative discovered the resident on oxygen during a visit. The nurse later apologized for not notifying either of the resident's representatives about the change in condition. There was no documentation to show that the representative was informed at the time of the significant health status change or when the treatment plan was altered.