Failure to Notify Resident's Representative After Contraband Incident
Penalty
Summary
The facility failed to notify a resident's representative after an incident involving contraband was discovered in the resident's room. The resident, who had a diagnosis of unspecified schizophrenia and moderate cognitive impairment, was found with a metal fork, considered contraband per unit policy. Staff retrieved the item and counseled the resident, but there was no documentation that the resident's representative was informed of the incident. Multiple staff members, including two program counselors and an LVN, acknowledged during interviews that they did not notify the representative, each assuming another staff member would do so or not realizing the incident was new. Facility policy required prompt notification of a resident's representative in the event of changes in the resident's condition or status, including significant changes in mental or psychosocial status. Despite this, the incident was not communicated to the representative, as confirmed by the Director of Nursing. The lack of notification was documented in the resident's progress notes and corroborated by staff interviews.