Failure to Notify Responsible Party After Resident's Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's responsible party after the resident experienced a significant change in condition. According to the facility's Notification of Change policy, staff are required to promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification, such as accidents resulting in injury or those with the potential to require physician intervention. Review of the resident's records showed that the resident, who was assessed as moderately cognitively impaired, sustained a humeral fracture as confirmed by x-ray. The results were reviewed with the physician, but there was no documentation or evidence that the resident's guardian was notified of the fracture. Interviews with the resident's guardian confirmed that they were not informed about the injury. Further interviews with facility staff, including an LPN, the administrator, and the DON, all indicated that staff are directed to contact the resident's family or guardian in the event of a change in condition. Despite this policy and staff understanding, the required notification to the resident's guardian did not occur following the resident's fracture.