Failure to Notify Resident Representative of Fall, UTI, and Antibiotic Initiation
Penalty
Summary
The facility failed to notify a resident's representative regarding significant changes in the resident's condition and treatment. Specifically, the representative was not informed when the resident experienced an unwitnessed fall resulting in a skin tear and bruising on the right hand, wrist, and forearm. Nursing progress notes documented the fall and resulting injuries but did not indicate that the resident's representative was notified of the incident, as required by facility policy. Additionally, the facility did not notify the representative when the resident was diagnosed with a urinary tract infection (UTI) and subsequently started on antibiotics. Although staff believed the representative was aware that a urine specimen was being collected, there was no documentation or confirmation that the representative was informed of the UTI diagnosis or the initiation of antibiotic treatment. The facility's policy requires notification of family or representatives in the event of accidents resulting in injury or significant changes in treatment, which was not followed in these instances.