Failure to Notify Resident and Family of Change in Condition and Treatment
Penalty
Summary
The facility failed to inform a resident and her family member about a significant change in her medical condition and the subsequent plan of treatment following an episode of hypoglycemia. The resident, who was cognitively intact and had multiple diagnoses including diabetes, was found unresponsive and lethargic with a blood sugar level of 41 mg/dl. Staff attempted to administer sugar orally but were unsuccessful, and emergency services were called. Paramedics administered IV dextrose, after which the resident's blood sugar increased and she returned to her baseline condition. Despite the severity of the incident, there was no documentation that the resident or her family member was notified about the change in condition or the treatment provided. Interviews with nursing staff and the Assistant Director of Nursing (ADON) revealed that the facility's policy required immediate notification of the resident and their representative in the event of a significant change in condition. However, the ADON and nursing staff acknowledged that this communication and documentation did not occur as required. The facility's policies also mandated that residents be informed of their medical condition and participate in care planning, which was not followed in this case. Record reviews and staff interviews confirmed that there was no evidence in the progress notes or other documentation that the resident or her family member was educated or informed about the hypoglycemic episode or any changes to the care plan. The ADON and nursing staff admitted that information should have been provided and documented, but this was not done. The failure to communicate and document the change in condition and treatment plan constituted a violation of the facility's own policies and federal requirements regarding resident rights and notification.