Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition. The resident, who was cognitively intact and had a history of cerebrovascular disease, hypertension, apnea, and peripheral vascular disease, experienced unusual fatigue, refused breakfast, and would not get out of bed or speak as usual. Medical interventions were initiated, including oxygen therapy, CPAP, IV fluids, and administration of Narcan, with the provider and nurse manager involved in the resident's care. Despite these significant changes and interventions, there was no documentation that the resident's family was notified at the time of the change. Interviews with facility staff revealed that the nurse manager assumed the floor nurse would notify the family, but could not find any documentation to confirm this. The nurse who provided care during the initial change stated that she attempted to call the resident's daughter but only reached voicemail and did not document the attempt or pass the information to the oncoming nurse. The nurse who took over the next shift believed the family had already been notified and only contacted them at the end of her shift, at which point the family expressed upset at not being informed sooner about the resident's condition and interventions. The facility's policy requires prompt notification of the resident's representative in the event of significant changes in condition, including the initiation of new treatments or clinical complications. In this case, the responsible party notification section in the electronic medical record was left blank, and staff interviews confirmed that the required notification did not occur in a timely manner, resulting in the family not being informed of the resident's change in condition until the following day.