Failure to Notify Responsible Party of Resident's Change of Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change of condition. The resident, who had a cognitive communication deficit and aphasia, was admitted with severe cognitive impairment as indicated by a BIMS score of 0. On a specific date, a registered nurse documented that the resident's right big toe had a foul smell and that a referral to podiatry would be made. However, there was no documentation that the RP was informed of this change in the resident's condition. During interviews and record reviews, both the RN and the Director of Nursing (DON) were unable to find evidence that the RP had been notified about the resident's condition. The RN could not recall informing the RP, and the DON confirmed that facility policy requires notification of the physician and RP in the event of a change of condition. The facility's policy also specifies that residents, family, legal representatives, and physicians must be informed of significant changes in condition or treatment needs.