Failure to Assess, Document, and Notify Changes in Resident Condition
Penalty
Summary
The facility failed to ensure proper assessment and notification procedures were followed for a resident who experienced multiple changes in condition. Specifically, when the resident was observed with a bloodshot right eye, there was no documentation of a change in condition (COC) assessment, such as an SBAR, in the medical record. The Director of Nursing (DON) confirmed that neither an assessment nor appropriate documentation was completed, despite facility policy requiring such documentation for changes in a resident's medical or mental condition. Additionally, the facility's policy on charting and documentation mandates that all changes in a resident's condition be recorded in the medical record, which was not done in this instance. Following a fall incident, the facility did not complete a post-fall risk assessment for the resident, as required by both the facility's orientation materials and its policy on assessing falls and their causes. The DON acknowledged that a post-fall assessment was not performed or documented, and that the facility's procedures require such an assessment after a fall. The lack of documentation and assessment meant that the resident's medical record did not accurately reflect the incident or the resident's subsequent risk status. Furthermore, the facility did not notify the resident's family of the changes in condition, including the fall and the bloodshot eye, as required by facility policy. The DON and a licensed nurse both stated that it is standard practice to notify family members after such incidents, but there was no evidence that this occurred. Additionally, the Interdisciplinary Team (IDT) meeting to review the resident's changes in condition was not conducted within the required 72-hour timeframe, with the DON confirming the delay. These failures resulted in incomplete communication and documentation regarding the resident's care and condition.