Failure to Notify Responsible Party of Resident Condition Changes
Penalty
Summary
The facility failed to notify the responsible party of changes in condition and treatment for one resident who was admitted with traumatic brain dysfunction, aphasia, and hemiplegia, and was documented as severely cognitively impaired. The resident's guardian, listed as the primary contact, reported not being consistently informed of changes in the resident's status or care, including illness, medication changes, and new treatments. The guardian stated that she only learned of the resident's pneumonia and antibiotic treatment after proactively contacting the facility herself. A review of the electronic medical record (EMR) revealed multiple instances where significant changes in the resident's condition or treatment were not communicated to the guardian. These included new medication orders, medication changes, catheterization for a urine specimen, respiratory changes requiring new interventions, gradual dose reduction and discontinuation of psychotropic medication, initiation of treatment for an open skin area, and ongoing weight loss. In each case, there was no documentation that the guardian had been notified. The Director of Nursing acknowledged the lack of documentation and indicated a review would be conducted, but as of the survey exit, no evidence was provided that the guardian had been informed of these matters.