Failure to Notify Representatives of Significant Change in Condition
Penalty
Summary
The facility failed to notify residents' representatives of significant changes in condition for two out of three residents reviewed, as required by both facility policy and federal regulations. In both cases, the facility did not ensure that the residents' current designated representatives' names and contact information were updated in the electronic medical record (EMR). Additionally, when representatives were unreachable, staff did not make additional attempts or try alternative methods to contact them, nor did they document multiple attempts as expected. For one resident, who was cognitively intact and had multiple chronic conditions including COPD, atrial fibrillation, and diabetes, the facility made only a single attempt to contact the representative when the resident was hospitalized. No message was left, and there was no documentation of further attempts to notify the representative. The resident confirmed that the contact information in the EMR was correct and expressed distress that his representative was not informed of his hospitalization, only learning of it when the resident himself called. Another resident, also cognitively intact and with chronic heart failure, COPD, and bipolar disorder, reported that her representative was not notified of her hospitalizations on multiple occasions. The EMR contained outdated information, listing a deceased individual as her representative. The resident stated that the facility did not verify or update her representative's information during her stay or at care conferences, and she was unsure how to ensure the information was current. Staff interviews revealed inconsistent practices regarding updating and verifying representative contact information, and there was no official procedure in place to ensure accuracy or follow-up when notification attempts were unsuccessful.