Failure to Notify Resident Representatives of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative party (RP) of a change in condition or transfer for two out of seven residents reviewed for changes. In one case, a resident was transferred to the emergency room due to a change in condition, including decreased activity and lack of urine output, without prior notification to the RP. The RP only learned of the transfer upon seeing the resident at the hospital and subsequently called the facility for information. Documentation in the electronic medical record confirmed that the family was not notified until after the transfer had occurred and only after the RP initiated contact. In another case, a resident with multiple diagnoses, including heart failure, diabetes, and dementia, sustained a minimally displaced fracture of the right heel. The resident was dependent on staff for all activities of daily living and required total assistance. The facility's records showed that the designated family member was not informed of the injury, despite being listed as the emergency contact and substitute decision-maker. Attempts to contact the family member were unsuccessful due to a non-working phone number, and there was no evidence that the notification responsibility was handed off to the next shift as per the facility's stated practice. Interviews with staff and review of facility policy revealed that there was no formal policy for notification of change in condition. The interim director of nursing confirmed that the charge nurse was responsible for notification, but this was not consistently documented or carried out. The lack of a clear policy and failure to ensure notification led to the deficiency, as family members were not informed in a timely manner about significant changes in the residents' conditions.