Failure to Notify Representatives and Providers of Resident Condition Changes
Penalty
Summary
The facility failed to notify resident representatives and/or medical providers of changes in condition or care for three residents. In one case, a resident with cirrhosis and a hip fracture complained of feeling unwell and cold throughout the night, but there was no documentation that the provider was notified of these symptoms prior to the resident being found unresponsive and subsequently pronounced deceased. The resident's son and physician were only notified after the resident's death. In another instance, a resident with schizophrenia and paraplegia had a diet change from mechanical soft to pureed, but the legal guardian and responsible party was not informed of this change, leading to questions from the family about the resident's medications and dietary modifications. Additionally, a resident with COPD, lung cancer, and dementia was transferred to the hospital for altered mental status and behavioral concerns without notification to the emergency contact or legal guardian. Documentation failed to show that the family was informed of the transfer, and family-submitted information confirmed they were not notified. The Nursing Home Administrator and Director of Nursing confirmed these failures to notify the appropriate parties regarding changes in condition or care for these residents.