Failure to Notify Family of Change in Condition and New Medication
Penalty
Summary
The facility failed to inform the family of a resident's change in condition, specifically regarding a low potassium level and the initiation of potassium supplementation. The resident, who was admitted for respite and hospice care, had multiple diagnoses including transient ischemic accident, congestive heart failure, cerebrovascular accident, stage 4 chronic kidney disease, and hypertension. Laboratory results showed a potassium level below the acceptable range, and the resident was subsequently started on potassium as ordered by the physician. However, there was no documentation in the progress notes indicating that the family was notified of the abnormal lab result or the new medication. During interviews, the DON confirmed that the facility's policy requires prompt notification of the resident's representative when there is a significant change in the resident's condition or when new medications are started. The DON acknowledged that the family should have been notified of the low potassium and the initiation of potassium therapy. Review of the facility's policy further supported the expectation for family notification and documentation in the medical record, which was not observed in this case.