Failure to Notify Resident's Representative of Significant Change and Restraint Use
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition and treatment, specifically regarding the use of a physical restraint and a referral to an inpatient psychiatric facility. According to facility policy, the representative must be immediately informed of significant changes in the resident's physical, mental, or psychosocial status, as well as any significant alterations in treatment. Documentation showed that a nurse practitioner ordered a wrist restraint and a transfer to an inpatient psychiatric facility for a resident with moderately impaired cognition, as indicated by a BIMS score of 09 and diagnoses including cerebral palsy and intellectual disabilities. Although a progress note indicated that a family member was notified of the resident's behaviors, the new restraint order, and the psychiatric referral, the resident's designated representative and POA was not contacted. The responsible party/POA later reported not being informed of these developments. The ADON confirmed that the charge nurse failed to notify the resident's representative/POA and instead contacted another family member, contrary to facility policy.