Failure to Notify POA/Family of Resident's Self-Harm Statements
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) or family of a resident who expressed self-harm thoughts. The resident, who had diagnoses of depression and dementia and was documented as cognitively intact, reported feeling upset about his situation and made statements indicating suicidal ideation. Documentation showed that the physician was notified, but there was no evidence in the progress notes that the POA or family was informed of the resident's self-harm statements. The resident's care plan did not reflect his depression diagnosis, and the social worker did not interview the resident on the day of the incident due to being out of the facility. Both the Assistant Director of Nursing (ADON) and the social worker indicated that notifying the family would typically be part of the process, but this was not done in this case. Interviews with the resident's POA/wife confirmed she was not made aware of the resident's self-harm statements at the time, only learning about it later and subsequently taking steps to remove firearms from the home. The facility's policy requires immediate notification of family or POA by telephone in the event of any incident or significant change in condition, with documentation of each attempt in the nurse's notes. However, there was no documentation that the family or POA was notified as required by policy.