Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition. Specifically, a resident with multiple complex medical diagnoses, including diabetes with a foot ulcer, cognitive impairment, and a history of traumatic brain injury, was found to have new skin abrasions. Although the facility's records indicated that management and the physician were updated, the documentation stated the resident was his own responsible party, despite a severely impaired cognition score (BIMS of 2) and ongoing guardianship proceedings. Interviews revealed that the resident's spouse was not always informed of changes in the resident's care, and communication from the facility was described as inadequate. Facility policy required notification of a representative in cases where the resident was not competent or was in the process of obtaining guardianship. However, in this instance, the next of kin was not notified of the change in condition, contrary to policy and regulatory requirements.