Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative regarding a significant change in condition for one resident. The resident, who had diagnoses including paranoid schizophrenia, hypertension, and gastro-esophageal reflux disease, was noted to be mildly cognitively impaired. On the day in question, the resident was found to be cool, clammy, tachycardic, and hypertensive, and refused both blood pressure medication and fluids. Nursing notes from this period did not document any notification to the resident's family or representative about these changes in condition. Later that day, the resident continued to exhibit symptoms such as excessive sweating, tachycardia, hypertension, and tachypnea, and again refused medications and fluids. The nurse practitioner was contacted and ordered the resident to be sent to the emergency room, at which point the resident's representative was informed of the transfer. Interviews with staff confirmed that the expectation was to notify the resident's representative when a change in condition was identified, and that this should be documented in the progress notes. However, the initial significant change in the resident's condition was not communicated to the representative as required by facility policy.