Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition involving the initiation of intravenous fluids and antibiotics. According to the facility's policy, the interdisciplinary team is required to communicate with residents and/or families or responsible parties when there is a change in clinical condition, including changes in medication. For one resident with diagnoses including acute respiratory failure with hypoxia, pneumonitis due to inhalation, and dementia, physician orders were initiated for IV sodium chloride and oral levofloxacin for pneumonia. Documentation in the electronic medical record confirmed the administration of these treatments, but there was no evidence that the responsible party was notified of these changes. Staff interviews revealed that the LPN responsible for the resident's care could not recall if the family or responsible party had been notified and did not believe any such notification was documented. The unit manager confirmed that changes in medication or clinical condition should prompt family notification. The Director of Nursing acknowledged that the responsible party had not been notified and that a grievance had been filed by the family. The lack of notification was not in accordance with facility policy and resulted in the responsible party not being informed of the resident's change in condition.