Failure to Notify Responsible Parties and Physicians of Resident Changes in Condition
Penalty
Summary
The facility failed to ensure proper notification of a resident's public guardian or responsible party, as well as the resident's physician, when two residents experienced significant changes in condition. In the first instance, a resident with severe cognitive impairment and multiple diagnoses, including dementia and stroke, was transferred to a general acute care hospital due to a change in condition. The resident's admission record incorrectly listed her as self-responsible, and emergency contact numbers were outdated. As a result, no responsible party or public guardian was notified of the transfer. The social services designee acknowledged that the admission record was not updated and that there was no system in place to ensure consistency between the admission record and the resident's medical documentation, leading to a failure to initiate the process for appointing a public guardian. In the second case, another resident with a history of bradycardia, syncope, hypertension, and major depressive disorder had physician orders for continuous heart rate monitoring and specific parameters for physician notification. The resident's heart rate was recorded outside the prescribed parameters on multiple occasions, and the resident was also non-compliant with wearing a cardiac monitor. Despite these significant changes, there was no documented evidence that the physician was notified as required by the care plan and physician orders. Nursing staff confirmed that they did not communicate these changes to the physician, and the director of nursing acknowledged that this failure could have resulted in delayed medical intervention. Facility policy and procedure required prompt notification of a resident's family, representative, or physician in the event of significant changes in condition, refusal of treatment, or transfer to another care setting. The investigation found that these policies were not followed in the cases reviewed, resulting in a lack of timely and appropriate notification to responsible parties and physicians when residents experienced changes in condition or required medical intervention.