Failure to Notify Resident Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to notify the resident's representative (DPOA) of a change in condition that required testing and treatment for a urinary tract infection (UTI) in one resident. The resident, who had a primary diagnosis of bipolar disorder and was dependent on staff for toileting and hygiene, exhibited symptoms such as behavioral changes, cloudy urine, burning sensation during urination, urgency, frequency, and dysuria. A physician ordered a urinalysis with culture and sensitivity, which confirmed the presence of infection, and subsequently ordered a course of intramuscular antibiotics. Despite these significant changes in the resident's condition and the initiation of new treatment, there was no documentation in the electronic medical record that the DPOA was notified of the symptoms, testing, results, or the antibiotic therapy. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the expectation was for immediate notification of the resident's representative in such circumstances, with documentation in the progress notes. The DPOA also confirmed not being informed by staff about the resident's change in condition, testing, or treatment, learning of these events only from the resident during a subsequent hospital visit. The facility's policy required prompt notification of the resident's representative when there is a change requiring such notification, including new treatments, but this was not followed in this instance.