Failure to Notify Physician and Responsible Party of Resident's Decline in Mobility and ADLs
Penalty
Summary
The facility failed to promptly notify the physician and responsible party of a significant change in condition for a resident who experienced a decline in mobility and increased dependency in activities of daily living (ADLs). The resident, who had diagnoses including dementia, Alzheimer's disease, diabetes mellitus, and muscle weakness, was initially able to walk independently or with a walker and required only moderate assistance with ADLs. Over time, the resident became increasingly dependent, eventually requiring a wheelchair and mechanical lift for transfers, and was no longer able to stand or walk. Despite this notable decline, there was no documented evidence in the electronic medical record of a timely assessment or physician notification regarding the resident's change in condition. Interviews with therapy staff, nursing staff, and the responsible party confirmed that the decline was observed but not communicated to the physician or responsible party as required. The responsible party reported noticing the resident spending more time in bed and sleeping more, but stated that these changes were not discussed with him by the facility. Therapy staff were also unaware of the resident's current status and had not been referred for reassessment. The facility's policy required documentation of assessment findings and prompt notification of the physician and responsible party in the event of a change in condition. However, both the MDS nurse and DON confirmed that the significant decline in the resident's functional status was not properly assessed or communicated, and the physician stated he was not aware of the change. This lack of timely notification and assessment constituted the deficiency identified by surveyors.