Failure to Notify Resident's Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition and new treatments, as required by facility policy and regulatory standards. The resident in question had a history of Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, and obesity, and was identified as having moderate cognitive impairment with a BIMS score of 8/15. On the date in question, the resident experienced acute respiratory symptoms, including low oxygen saturation, irregular heart rate, and purple nail beds, which led to the administration of breathing treatments, diuretics, and steroids. The medical provider documented that the resident was high-risk and had a significant change in condition, resulting in new orders for antibiotics, steroids, and other medications. Despite these significant clinical changes and interventions, there was no documentation in the clinical record that the resident's representative was notified of the change in condition or new treatments. Interviews with the NHA and DON revealed that staff believed the resident did not want family notified, but there was no documentation to support this, and the resident stated a preference for family notification. The facility's policy required documentation of such notifications, including who was informed and their response, but this was not present in the record.