Failure to Notify Representatives and Physicians of Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify a resident's representative and physician when a BiPAP machine malfunctioned for a resident with chronic respiratory failure and obstructive sleep apnea. The medical record showed that the BiPAP was not administered due to device dysfunction, and while the supplier was contacted and a replacement was arranged, there was no documentation that the resident's representative or physician was informed of the situation or the change in the resident's respiratory support status. Additionally, staff did not notify another resident's representative in a timely manner when the resident, who had dementia, was transferred to the hospital after being found unarousable. The representative was only informed after the hospital had already made contact. Documentation confirmed the delay in notification, and the DON verified that timely notification did not occur in both cases.