Failure to Promptly Notify Family of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's family member in a timely manner following a significant change in the resident's condition. On the morning of 4/13/2025, a resident was noted to have a change in condition, including hypoxia and respiratory distress, with an SPO2 of 89% that improved to 94% after oxygen was administered. The nurse on duty at the time notified hospice but did not promptly inform the resident's family member of the change. The nurse stated that notifying the family was not a priority and that the patient came first, and subsequently left the responsibility of notifying the family to the oncoming nurse at shift change. The oncoming nurse later discovered that the family had not been notified and subsequently called the resident's family member at 11:15 AM, several hours after the change in condition was first identified. The family member confirmed receiving the call late in the morning and expressed concern that the night shift nurse had left without providing notification. The facility's policy requires prompt notification of both the physician and the family when a change in condition occurs. The Director of Nursing confirmed that the nurse should have notified the family promptly as per facility policy.