Failure to Document Family Notification of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to document family notification regarding a significant change in condition for a resident with multiple diagnoses, including diabetes, Parkinson's disease, and Alzheimer's disease. The resident was assessed by an APRN for a congested cough with thick secretions, and a chest x-ray revealed modest left basilar pneumonia. Following this, an antibiotic was ordered and initiated. However, there was no documentation in the clinical record that the family or responsible party was notified about the change in condition, the diagnostic testing, the results, or the new treatment. Interviews with the Director of Nursing Services (DNS) and a Registered Nurse (RN) confirmed that it was the nurse or nurse supervisor's responsibility to notify the family and document this in the clinical record. Although the daily nursing supervisor report indicated that a message was left for the family, this report was not part of the resident's clinical record. The RN involved stated she was unaware of the requirement to document family notification in the clinical record. Facility policy required that such notifications and changes be documented in the electronic record, but this was not done in this instance.