Failure to Notify Emergency Contact of Change in Resident Condition
Penalty
Summary
The facility failed to notify the emergency contact of a resident who experienced a change in condition. According to the facility's policy, staff are required to inform the resident, consult with the resident's physician, and notify the legal representative or interested family member of significant changes in the resident's physical, mental, or psychosocial status. In this case, a resident with severely impaired cognition and multiple diagnoses, including dysarthria, anarthria, hemiplegia, and dementia, was noted to be lethargic, less talkative than usual, and had decreased food and fluid intake. The nurse contacted the on-call provider, who advised continued monitoring and for the resident to be seen by the primary care physician. The nurse continued to monitor the resident throughout the shift and documented the resident's vital signs and condition. However, there was no documentation that the resident's emergency contact was notified of this change in condition. During an interview, an LPN reviewed the nurse's progress note and confirmed that there was no evidence of family notification, stating that the family should have been informed of any change in condition. This lack of notification was identified for one of three sampled residents reviewed for notification of change, out of a total of 38 residents in the facility.