Failure to Notify POA of Change in Condition
Penalty
Summary
The facility failed to notify the power of attorney (POA) of a resident's change in condition, as required by both the resident's special instructions and facility policy. The resident, who had diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity, was dependent on staff for activities of daily living but had intact cognition. The medical record indicated that the POA requested to be notified of any behaviors or concerns. Despite this, there was no documented evidence that the POA was informed when the resident experienced significant changes in condition, including episodes of bleeding that required hospital transfer, worsening symptoms such as shortness of breath and grogginess, and subsequent returns from the hospital. Nursing progress notes showed that while medical staff and nurse practitioners were notified of the resident's condition changes and hospital transfers, the POA was not notified at any point during these events. Interviews with the resident and the Director of Nursing confirmed that the POA was not informed as required, and the facility's policy stated that the resident, physician, and family/POA/guardian should be promptly notified of changes in medical status. This deficiency was identified during a complaint investigation and affected one resident out of four reviewed for notification of change in condition.