Failure to Timely Notify Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to notify the resident's representative (RR 2) when the resident experienced vomiting early in the morning. The resident, who had a history of senile degeneration of the brain and major depressive disorder, was later transferred to the hospital the same day after developing a high fever and weakness. Documentation showed that the physician was notified of the vomiting, but there was no record that RR 2 was informed at that time. Notification to RR 2 only occurred later in the day when the resident's condition had worsened. Interviews with RR 2 confirmed that she was not made aware of the vomiting episode until after the resident's condition had deteriorated. Facility staff, including the Assistant Director of Nursing and Unit Manager, acknowledged that RR 2 was listed as the resident's representative and emergency contact and should have been notified of the change in condition. Clinical records and interviews confirmed the lack of timely notification to the resident's representative regarding the initial change in condition.