Failure to Notify Physicians and Representatives of Changes in Condition
Penalty
Summary
The facility failed to notify physicians and resident representatives of significant changes in condition or treatment for four residents. For one resident with a history of cancer, dysphagia, and a feeding tube, there were multiple refusals of enteral and oral feedings, as well as a documented weight loss of 5 pounds in one week and a total loss of over 25 pounds since the previous year. Despite care plan interventions requiring physician notification for significant weight loss and feeding refusals, there was no evidence that the physician was informed of these changes. Staff interviews confirmed that such notifications should have occurred, and the physician stated she was only recently made aware of the resident's weight loss and refusals. Another resident with diabetes and psychiatric diagnoses experienced a change in psychotropic medication and a critically high blood sugar reading. The resident's Power of Attorney (POA) was not notified of the medication change until behavioral symptoms emerged, and there was a delay in notifying both the POA and physician about the high blood sugar. Documentation of physician notification and orders for insulin was lacking in the medical record, and staff confirmed that notification should have been made for such changes in condition. Additional deficiencies included failure to notify a resident's family of a positive Covid-19 test result and failure to inform a family member of a fall resulting in injury, despite care plan interventions and facility policy requiring such notifications. In one case, the family only learned of a positive Covid-19 result after calling the facility following an automated message, and in another, the family was not informed of a fall with injury until contacted by hospice. The facility's policy required timely notification of changes in condition, but documentation and interviews revealed that these notifications were not consistently made.