Failure to Timely Notify Physician and Representative of Changes in Condition
Penalty
Summary
Facility staff failed to timely notify the physician and the resident or their representative of significant changes in condition for two residents. For one resident with diagnoses including urinary tract infection, urine retention, pressure ulcers, and renal insufficiency, there were multiple documented changes in condition and treatment, such as the onset of a urinary tract infection requiring intravenous antibiotics, the insertion of a PICC line, and the development of unstageable pressure ulcers. Despite these events, there was no documentation that the resident or their responsible party was informed of these changes until several days later, and the responsible party expressed concern about the lack of timely notification. In another case, a resident with severe cognitive impairment and dependent on a feeding tube experienced a dislodgement of the enteral feeding tube. The incident was discovered when the resident was sent out for a neurology appointment, and the family member present at the appointment noticed the absence of the tube and bleeding at the stoma site. Documentation did not show that the family or physician was notified of the dislodgement prior to the resident being sent out for medical attention. Interviews with staff and administration confirmed that the expected notifications did not occur as required. Facility policy requires prompt notification of the resident, physician, and representative of changes in condition, but in both cases, there was a lack of timely communication and documentation regarding significant changes in the residents' medical status. No additional information or evidence of timely notification was provided prior to the survey exit.