Failure to Notify Dialysis Clinic of Resident's Significant Change in Condition
Penalty
Summary
The facility failed to notify a dialysis clinic of a significant change in a resident's status following a fall that resulted in a subdural hematoma and scalp laceration. According to the facility's policy, any change in a resident's medical status, including physical injuries, must be communicated to relevant parties. Despite this, there was no documentation that the dialysis clinic was informed of the resident's fall or subsequent diagnosis of a subdural hematoma. Staff interviews confirmed that communication with the dialysis clinic is typically conducted using a specific form, but review of these forms showed no mention of the incident or diagnosis. The dialysis clinic only became aware of the fall when the resident self-reported, and the clinic manager confirmed there was no official notification from the facility. The resident involved had a history of end-stage renal disease and falls, and was cognitively intact at the time of the incident. The lack of communication was confirmed by multiple staff members, including the nurse practitioner, LPN, DON, and the administrator, all of whom acknowledged that the dialysis clinic should have been notified due to the potential impact on treatment, specifically the administration of anticoagulants. Review of progress notes and communication forms further substantiated that the required notification did not occur.