Failure to Notify Responsible Party of New Therapy Order
Penalty
Summary
The facility failed to notify a resident's responsible party of a new order for physical and occupational therapy evaluation and treatment. Medical record review showed that the order was signed by an LPN, but the section for family notification was left blank, and there was no documentation in the record indicating that the responsible party had been informed. During an interview, the LPN confirmed she was responsible for signing the order and assumed she had notified the responsible party, but acknowledged there was no documented evidence of such notification. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, morbid obesity, hemiplegia and hemiparesis following a cerebral infarction, hyperlipidemia, atrial fibrillation, depression, dementia, anxiety, legal blindness, mood disorder, insomnia, and dysphagia. The resident's quarterly MDS assessment indicated moderately impaired cognition. Facility policy required the unit supervisor or charge nurse to notify the guardian or interested family member of significant changes in a resident's clinical condition or status, including changes in ADL physical functioning, and to document the notification. This policy was not followed in this instance.