Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a change in condition was reported to the provider on two separate occasions for a resident with severe cognitive impairment, dementia, diabetes, and anxiety disorder. The resident was known to wander and had a care plan in place to monitor for changes in mental status and ensure a safe environment. On one occasion, a nurse documented that the resident was lethargic and had decreased meal consumption, but only the decreased meal intake was reported to the provider. The provider was present in the facility at the time and stated that, had they been informed of the lethargy, they would have evaluated the resident further. On a subsequent occasion, the resident experienced a fall after tripping near the nurse's station. Following the fall, the resident, who was typically very active and ambulatory, remained in bed for the rest of the day, which was unusual for their baseline behavior. Both the day and evening shift LPNs observed this change in activity level but did not notify the provider of the resident's altered condition. The provider later confirmed that remaining in bed was a significant change for this resident and should have been reported. The facility's policy required that any significant change in a resident's physical, mental, or psychosocial status be evaluated, documented, and reported to the provider and the resident's representative. Interviews with staff and review of documentation confirmed that these requirements were not met in both instances, resulting in a failure to follow the facility's change of condition policy.