Failure to Notify Legal Guardian of Resident's Change in Condition
Penalty
Summary
The facility failed to honor a resident's rights by not notifying the court-appointed legal guardian of multiple changes in the resident's medical condition. The resident, who had diagnoses including acute on chronic congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, unspecified dementia, and dysphagia, was determined to have severely impaired cognition with a BIMS score of 6. Documentation confirmed the presence of a permanent legal guardian, and the resident's electronic medical record included the guardian's contact information. Despite this, there was no evidence that the legal guardian was notified of significant changes in the resident's condition, such as elevated INR, uncontrolled blood glucose, medication adjustments, new orders for diagnostic procedures, or care conferences. Multiple notes in the resident's medical record indicated that only the resident was notified of these changes, even though the resident was not cognitively capable of making informed decisions. Staff interviews confirmed that facility policy and staff understanding required notification of the legal guardian in such cases, regardless of the resident's wishes, due to the guardian's court-appointed authority. However, the documentation repeatedly showed that the legal guardian was not informed during several key events, including medication changes, new diagnoses, and care planning meetings. Facility policies reviewed stated that residents or their responsible agents must be informed of changes in condition and that legal guardians are to be involved in decision-making for residents deemed incapacitated. Despite these policies, the facility did not consistently communicate with the legal guardian as required, as evidenced by the lack of documentation of such notifications during multiple changes in the resident's condition and care.