Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's family or representative of significant changes in the resident's condition, as required by facility policy. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, hypotension, and syncope, experienced multiple syncopal episodes and a fall over several days. Documentation showed that after an unwitnessed fall, the resident declined family notification, but during subsequent syncopal episodes—one resulting in a skin tear and another in moderate leg pain—there was no documentation that the provider or family/HCPOA were notified. Only after a further decline, when the resident exhibited loss of range of motion and was found to have a hip fracture, were the provider and family notified and the resident sent to the hospital. Interviews with staff confirmed that the charge nurse is responsible for notifying the provider and family after significant changes, and that if a resident is their own decision maker, they are asked about family notification. The Director of Nursing stated that the resident had expressed a preference for family notification, but there was no documentation to confirm that the resident was asked or that the family was notified after each incident. The resident's family member also reported not being notified of the earlier incidents, only learning of the situation when the resident was being transferred to the hospital for evaluation.