Failure to Notify Resident Representative of Significant Change in Condition and Treatment
Penalty
Summary
The facility failed to notify the resident's representative of significant changes in the resident's condition and treatments. The resident, who had diagnoses including dementia, muscle weakness, and stage 3 chronic kidney disease, experienced several notable changes in health status, such as fatigue, altered mental status, dark urine, congestion, fever, productive cough, lethargy, and abnormal vital signs. Although the family was notified when sodium chloride was ordered for dehydration, subsequent changes and new treatments, including the administration of D5W/NaCl and further sodium chloride infusions, were not communicated to the family as required by facility policy. Progress notes for these events did not indicate that the family had been informed. The deficiency was further highlighted by staff interviews and policy review. An LPN was unaware of the resident's death, and the DON confirmed the facility's policy required family notification for significant changes in condition or treatment. The lack of documentation and communication regarding the resident's deteriorating condition and new interventions directly led to the deficiency identified during the review.