Failure to Notify Resident Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to notify the resident's representative in a timely manner following changes to provider orders for a resident who was severely cognitively impaired and incontinent. The resident's care plan included monitoring for signs and symptoms of urinary tract infection (UTI) and reporting findings to the medical provider. After the family expressed concerns about increased confusion and requested a urinalysis, a urine sample was eventually obtained, and the resident was diagnosed with a UTI. An order for antibiotics was initiated, and sensitivities confirmed the continued use of the prescribed medication. Despite these significant changes in the resident's condition and treatment, there was no documentation in the progress notes that the resident's representative was notified after the urinalysis results, the UTI diagnosis, or the initiation of new medication orders. The family member reported not receiving updates about the resident's urine status or treatment and only learned about the antibiotic regimen after inquiring in person. The facility's policy required immediate notification and documentation of such changes, but this was not followed in this instance.