Failure to Notify Representatives of Significant Changes and Events
Penalty
Summary
The facility failed to ensure timely notification of residents' representatives regarding significant changes in condition, medical appointments, and medication changes for two residents. In one case, a resident with multiple diagnoses, including diabetes, dementia, and atrial fibrillation, was sent to a cardiology appointment and subsequently started on an anticoagulant medication. There was no documentation in the electronic medical record (EMR) that the resident's representative was notified of either the appointment or the new medication order. Both the resident and the former representative confirmed that the representative only learned of these events after being informed by the resident, not by the facility. In another instance, a resident with a history of falls and muscle weakness reported hip pain and difficulty bearing weight. Although the facility documented the resident's symptoms and planned for further assessment and notification, there was no evidence in the EMR that the representative was informed of the change in condition or the subsequent transfer to the hospital for X-rays. The representative stated he was not notified by the facility about the resident's change in mobility or hospital transfer until several hours after the event, learning of the situation first from the outpatient physician's office. Facility policy requires prompt notification of residents, their attending physicians, and representatives regarding changes in condition or status. However, interviews with facility leadership revealed there was no standardized process for such notifications or for documenting them in the EMR. The lack of timely and documented communication with residents' representatives regarding significant changes and events led to the identified deficiencies.