Failure to Notify Resident Representatives After Change in Condition
Penalty
Summary
The facility failed to notify resident representatives after significant changes in condition for two residents. One resident, with a history of metabolic encephalopathy, Parkinson's disease, and cerebral infarction, experienced a fall. Although the provider was notified, there was no documentation or evidence that the family was informed of the incident. Staff interviews confirmed that family notification was expected but not completed, and a review of the clinical record found no record of family contact. Another resident, admitted with dysphagia, hemiplegia, hemiparesis, cognitive communication deficit, and depression, was found outside the facility on two occasions. While staff redirected the resident and notified a corporate nurse, and later arranged for hospital transport, there was no documentation that the family was notified of either incident. Staff interviews and policy reviews confirmed that family notification was required but not documented in the clinical record for these events.