Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition and treatment, as required by facility policy and state regulations. Specifically, a resident with a history of cerebral infarction and colon neoplasm, who was moderately cognitively impaired, experienced several changes in condition, including episodes of emesis, administration of intravenous hydration and antibiotics, and a transfer to the hospital for evaluation due to a change in mental status. Documentation in the medical record did not show that the resident's representative was informed of the initiation of intravenous hydration, antibiotic therapy, or the transfer to the hospital. Interviews with facility staff, including LPNs, the Medical Director, and the DON, confirmed that it was the responsibility of licensed nurses, nurse practitioners, and medical doctors to notify resident representatives of changes in condition and to document such notifications. However, in this case, there was no evidence in the medical record that the required notifications were made or documented for the resident's representative during these significant events.