Failure to Notify Responsible Party of Change in Condition and New Medication Order
Penalty
Summary
The facility failed to ensure that responsible parties were notified in two separate instances for one resident. In the first instance, a resident with a history of hemiplegia, hemiparesis, cerebral infarction, muscle weakness, and bipolar disorder experienced a significant change in condition, including vomiting, inability to keep food, water, and medication down, increased confusion, and hallucinations. The physician ordered the resident to be sent to the emergency room, and documentation showed that the resident's spouse, who was also the roommate, was notified. However, there was no documentation that the designated HealthCare contact, the resident's daughter, was notified as required by facility policy. In the second instance, a new physician's order for alprazolam was issued for the same resident to address anxiety. Documentation indicated that the resident and the hospice company were notified of the new medication order, but again, there was no documentation that the HealthCare contact was informed. Interviews with staff confirmed that the daughter was listed as the HealthCare contact and should have been notified in both cases, but there were no notes indicating that this notification occurred.