Failure to Timely Notify Providers and Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to notify the attending physician, resident's representative, and registered dietitian in a timely manner when there were documented changes in residents' conditions. In one case, a resident who received all nutrition via tube feedings was identified as having severe malnutrition and was expected to gain weight. However, the resident experienced a significant weight loss of more than 5% in one week and nearly 8% in less than two weeks. Despite facility policy requiring immediate notification of significant weight changes, there was no documentation that the physician, nurse practitioner, registered dietitian, or responsible party were notified of the weight loss until more than a week after it was first identified. Nursing progress notes also failed to document the significant weight loss promptly, and the weight loss was not reported to the dietitian until ten days after it occurred. Additionally, the facility did not immediately notify the attending provider and representative of another resident's fall and subsequent changes in condition, including increased discomfort and changes in the appearance of a surgical incision. The fall and change in condition were reported two and five days later, respectively, rather than immediately as required. Interviews with the DON confirmed that changes in condition should be reported immediately, but the records showed delays in notification. These deficiencies were identified through record review and staff interviews, and were evident for one out of three complaints reviewed during the recertification survey and for one out of three residents reviewed for tube feeding. The lack of timely notification and documentation regarding significant changes in residents' conditions constituted a failure to follow facility policy and regulatory requirements.