Failure to Notify Physician and Resident Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to notify the appropriate parties, including physicians, nurse practitioners, and resident representatives, of significant changes in condition for three residents. For one resident with depression and end stage renal disease, there were multiple incidents at an outpatient dialysis center where the resident experienced auditory hallucinations, expressed suicidal ideation, and physically removed dialysis needles. Despite these events, documentation and interviews confirmed that the physician or nurse practitioner was not notified, although the resident’s family was informed. Nursing staff involved acknowledged the lack of physician notification, and the Assistant Director of Nursing was unaware of the incidents. Another resident with congestive heart failure and a history of wandering accessed a stairwell and exited the facility, ultimately being found in the parking lot. Although the resident was subsequently moved to a secure unit and placed on increased monitoring, the physician was not informed of the specific incident involving the stairwell and exit. The physician confirmed during interview that he was aware of the resident’s wandering behavior but was not notified about the stairwell elopement. A third resident, who had severe protein-calorie malnutrition and an appointed guardian, experienced a significant weight loss of 5.0% over a one-month period. The guardian was not notified of this change, and there was no documentation in the nutrition or nursing progress notes indicating that notification occurred. Staff interviews revealed a misunderstanding regarding the responsible party, with the dietitian not notifying the guardian due to incorrect information in the electronic medical record. The Director of Nursing confirmed that the guardian should have been notified of the weight loss.