Failure to Notify Physician and Guardian of Resident's Significant Condition Changes
Penalty
Summary
Facility staff failed to notify a resident's physician, nurse practitioner (NP), and guardian of significant changes in the resident's condition, including refusal of ordered diagnostic procedures, ongoing weight loss, and low blood pressure readings. The facility's policies required prompt notification of the resident, physician, and representative when there were changes in condition or treatment, but documentation and interviews revealed that these notifications did not consistently occur. Specifically, there was no evidence that the guardian, NP, or physician were informed when the resident refused a CT/Urogram, experienced notable weight loss over several months, or had low blood pressure readings while on antihypertensive medications. The resident involved had a history of severe cognitive impairment, bipolar disorder, and benign prostatic hypertrophy, and was under the care of a guardian due to impaired decision-making capacity. The resident's care plan and assessments indicated the need for involvement of the guardian in care decisions and highlighted the importance of notifying the physician and NP of changes in health status. Despite this, the medical record lacked documentation of notifications to the guardian or providers regarding the resident's refusal of diagnostic tests, significant and ongoing weight loss, and episodes of low blood pressure. The Registered Dietitian's notes also did not prompt documented communication with the NP or guardian regarding the resident's nutritional decline. Interviews with staff, the NP, and the resident's guardian confirmed that required notifications were not made. The NP stated he was not informed of the resident's refusal of an abdominal X-ray or of the low blood pressure readings, and the guardian reported not being notified of the resident's weight loss, low blood pressure, or refusal of procedures. Staff interviews revealed uncertainty or lack of recall regarding whether notifications were made, and the administrator acknowledged that staff should have communicated these changes to the NP and guardian. The deficiency centers on the facility's failure to follow its own policies for timely and appropriate notification of significant changes in a resident's condition.