Failure to Notify Guardian of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's court-appointed medical guardian when the resident experienced a significant change in condition and subsequent deterioration of a life-threatening condition. The resident, who had severe mental impairment and was dependent on staff for activities of daily living, was sent to the hospital for evaluation after being found with elevated respiration and unresponsiveness. Documentation showed that the medical provider was notified and orders were given to send the resident to the hospital, but there was no evidence that the guardian was contacted at the time of the transfer, as required by the resident's care plan. Interviews with facility staff, including an LPN, the DON, a social worker, and the assistant administrator, confirmed that the expectation was to notify the resident's representative or guardian immediately in the event of a significant change in condition. The guardian expressed disappointment at not being informed when the resident was sent to the hospital. The lack of documentation and failure to notify the guardian was attributed to an agency nurse not following facility policy.