Failure to Notify Resident Representative After Significant Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident's designated representative or emergency contact after a significant change in the resident's condition. Specifically, for one resident with severe cognitive impairment and multiple chronic diagnoses, including diabetes mellitus, Alzheimer's disease, anemia, chronic kidney disease, and COPD, there was no documentation that the resident's representative or emergency contact was notified when the resident experienced a decline in condition. The resident became lethargic, cold, and unresponsive, prompting staff to call EMS, who subsequently transported the resident to the hospital. Despite the presence of a family member at the facility during the incident, the emergency contact listed in the resident's records was not notified, and there was no documentation of any attempt to contact the designated representative. Interviews with staff and administration revealed a misunderstanding, as the administrator assumed the family member present would inform the emergency contact, contrary to facility policy, which requires direct notification by staff. This lapse resulted in a failure to ensure proper communication with the resident's representative during a critical change in the resident's status.