Failure to Notify Resident Representatives of Changes in Condition and Treatment
Penalty
Summary
The facility failed to ensure that resident representatives were notified when there were changes in residents' treatments or medications, as required by policy. In the case of one resident with anoxic brain damage, epilepsy, and other conditions, there were four documented occasions over five months where new orders or changes in condition occurred, but there was no evidence that the resident's designated representative, her sister, was notified. Although the resident was cognitively intact and able to communicate, she had expressed her desire for her sister to be informed of any changes, a preference that was not consistently honored or documented by the facility. Another resident with unspecified dementia and moderately impaired cognition had changes in condition and new orders issued on multiple occasions. The resident's son was listed as the primary emergency contact, but there was no documented evidence that he was notified of significant changes, including the discovery of a blood clot and new medication orders. While the resident's daughter was informed in one instance, the primary contact was not, and the facility's staff could not provide documentation to show that proper notification occurred as required. A third resident, diagnosed with Parkinson's disease, congestive heart failure, and moderate cognitive impairment, also experienced several changes in condition and new orders without evidence that his durable power of attorney for healthcare, his son, was notified. Despite the resident being made aware of the changes, the facility's policy and the resident's records indicated that the son should have been informed due to the resident's cognitive status and the son's legal authority. The DON confirmed that the notifications were not documented as required, and no additional evidence was provided to show that the representative had been informed.