Failure to Notify Resident Representative of Condition Changes and Treatment
Penalty
Summary
The facility failed to notify the designated representative of a resident with moderately impaired cognitive skills regarding significant changes in the resident's condition and treatment. The resident, who had a history of stroke, hypertension, diabetes, and non-Alzheimer's dementia, was started on intravenous antibiotics for cellulitis of the left foot and later developed a facility-acquired wound on the left second toe. Despite facility policy requiring timely notification and documentation of such changes to the resident's representative, there was no evidence that the family member listed as the emergency contact was informed about the initiation of intravenous antibiotics or the development and treatment of the wound. Interviews with staff confirmed that the family member was not notified prior to the administration of intravenous antibiotics or the discovery of the wound. The family member only became aware of the intravenous treatment after observing the resident bleeding from a dislodged IV catheter during a visit. The family member stated they would have refused the intravenous antibiotics and expressed a desire to be informed of any changes in the resident's condition or treatment. Staff interviews further revealed a lack of recall or documentation regarding family notification, and the Director of Nursing was unable to provide evidence that the required notifications had occurred.