Failure to Notify Families of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the families of two residents regarding significant changes in their conditions. For one resident with a history of falls and impaired balance, the family was not informed of a fall and subsequent mental status change until they visited and observed the change themselves. The resident's Power of Attorney confirmed that notification only occurred after the family discovered the incident, and the assigned nurse acknowledged that the family should have been contacted at the time of the fall but was not due to other tasks being prioritized. In another case, a resident with epilepsy and a seizure disorder experienced multiple seizures, but there was no documentation of family, physician, or palliative care notification following these events. The resident's care plan specifically required notification of palliative services with all changes in condition. The DON confirmed that staff are expected to monitor and notify the family and physician after a seizure, but this did not occur. The facility's policy also requires notification of the resident, physician, and family or legal representative when there is a change requiring such notification.