Failure to Notify Physician and Resident Representatives of Significant Changes and Incidents
Penalty
Summary
The facility failed to notify physicians and resident representatives of significant changes in resident status and incidents as required by policy and physician orders. For one resident with diabetes, there were multiple documented instances where blood glucose readings exceeded the threshold set by the physician's order, which required immediate physician notification. Despite this, nursing staff did not notify the physician or document such notifications in the clinical record, even though the physician expected to be informed to provide additional insulin coverage. Interviews with nursing staff confirmed that notifications were not made, and the Director of Nursing Services (DNS) stated that her expectation was for staff to follow the physician's order and document all notifications. For another resident with chronic kidney disease who frequently left the facility for dialysis and with family, staff repeatedly noted the resident returned smelling of marijuana. Although this was reported among staff and discussed in meetings, there was no documentation of physician notification, assessment, or notification to the dialysis center, as required by facility policy. The physician was not made aware of these ongoing issues, despite his expectation to be notified due to potential drug interactions with prescribed medications. The facility also lacked documentation of smoking assessments, education, or agreements for this resident, contrary to its own smoking policy. A third resident with a history of substance use and impaired cognition was involved in multiple incidents of suspected smoking and possession of smoking paraphernalia within the facility. Documentation showed that room searches were conducted and smoking materials were found, but there was a lack of evidence that the physician or the resident's representative was notified in most cases. The facility's own policies required such notifications and documentation, but interviews with staff and review of records confirmed these steps were not consistently followed. The only documented notification to the resident's representative occurred after a policy violation that led to discussions of discharge planning.