Failure to Notify Physician and Family of Resident Status Changes
Penalty
Summary
The facility failed to notify a resident's physician and daughter of significant changes in the resident's status, as required. The resident, who had diagnoses including chronic obstructive pulmonary disorder, diabetes, and congestive heart failure, was cognitively intact and listed as his own responsible party, with his daughter as the secondary contact. On multiple occasions, including when the resident was sent to the emergency room, refused treatments or medications, and did not return from a leave of absence, there was no evidence in the medical record that the physician or the resident's daughter were notified of these events. Progress notes documented the resident's refusals and hospital transfers, but lacked documentation of required notifications to the physician and family member. Additionally, the resident's daughter ultimately contacted the facility to report the resident's death, further indicating a lack of timely communication from the facility regarding the resident's status. Interviews with staff, including the Director of Nursing, confirmed inconsistencies in the notification process for significant changes, hospitalizations, refusals of treatment, and absences from the facility.