Failure to Notify Resident Representative of Change in Condition Due to Missing Contact Information
Penalty
Summary
The facility failed to timely notify a resident's representative of a change in the resident's condition. The resident, who had diagnoses including malignancies of the cardia, lymph, and lung, as well as type 2 diabetes, was admitted to the facility. On the following day, the resident was found hard to arouse in the early morning hours, prompting staff to check blood sugar, call 911 for hospital transport, notify the physician, and arrange for the resident's transfer to the hospital. However, the resident's husband was not notified of the hospitalization at the time because the facility did not have his contact information on file. Further review and staff interviews revealed that during the admission process, the LPN responsible for the nursing assessment did not obtain emergency contact information for the resident's representative, assuming that the social worker would collect this information. The social worker, in turn, relied on hospital demographic information and did not ensure the contact details were obtained directly from the resident or family. As a result, when the resident's husband arrived at the facility later that day, he was unaware of the transfer and only then provided his contact information, which was subsequently shared with the hospital.
Plan Of Correction
Plan of Correction F 0580 This Plan of Correction is prepared and executed because it is required by the provision of the State and Federal regulations and not because Mennonite Memorial Home agrees with the allegations and citations listed on this statement of deficiencies. Mennonite Memorial Home maintains that the alleged deficiencies do not, individually or collectively, jeopardize the health and safety of the residents, nor are they of such a character as to limit our capacity to render adequate care as prescribed by regulation. This Plan of Correction shall operate as the facility's written credible allegation of compliance as of 6/18/2025. By submitting this Plan of Correction, Mennonite Memorial Home does not admit to the accuracy of the deficiencies. This Plan of Correction is not meant to establish any standard of care, contract, obligation, or position and Mennonite Memorial Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. Immediate Corrective Action Taken for the Identified Resident(s): The resident identified in the survey had been identified by the facility. The staff at the facility attempted to obtain contact information for the resident's husband/responsible party. The medical record was updated accordingly. Identified other residents having potential to be affected by the same deficient practice and corrective action: Social Service reviewed all resident profile sheets on 4/23/2025 to assure emergency contacts were listed for all current residents living in the facility. All other residents had an emergency contact listed with a phone number. What measures will be put into place or what systemic changes will be made to ensure the deficient practice does not recur: Staff education was given on 6/6/2025 to the Social Service Department by the Administrator or his designee on filling out the profile page prior to admissions. Social Service will assure that resident #19 or like resident's responsible party information is correct for any needed notifications. Ongoing Monitoring so this deficient practice will not recur: The Director of Nursing or designee will monitor resident's profile sheets admitted 6/3/2025 or after for 4 weeks to assure proper responsible party information is present on the profile sheet. The DON or designee will perform weekly audits for 4 weeks on a sample of residents with a change in condition to ensure proper notification and documentation. This started on +6/6/2025. Results will be reported monthly to the Quality Assurance Committee with a phone number. What measures will be put into place or what systemic changes will be made to ensure the deficient practice does not recur: Staff education was given on 6/6/2025 to the Social Service Department by the Administrator or his designee on filling out the profile page prior to admissions. Social Service will assure that resident #19 or like resident's responsible party information is correct for any needed notifications. Ongoing Monitoring so this deficient practice will not recur: The Director of Nursing or designee will monitor resident's profile sheets admitted 6/3/2025 or after for 4 weeks to assure proper responsible party information is present on the profile sheet. The DON or designee will perform weekly audits for 4 weeks on a sample of residents with a change in condition to ensure proper notification and documentation. This started on +6/6/2025. Results will be reported monthly to the Quality Assurance Committee.