Failure to Notify Resident Representative of New Antibiotic Initiation
Penalty
Summary
The facility failed to notify the resident representative of the initiation of a new antibiotic for one of three residents reviewed. According to the facility's policy, the responsible party or guardian must be informed of changes in the resident's condition or occurrences, and the nurse is required to document the name of the person notified, along with the date and time, in the nurse's notes. For the resident in question, who had diagnoses including high blood pressure, depression, and heart failure, a new order for Keflex was started to treat cellulitis of the right hip. The physician's progress notes confirmed the clinical assessment and the start of the antibiotic treatment. However, a review of the resident's progress notes did not show any documentation that the resident's representative was notified about the new antibiotic. This was further confirmed during an interview with the Nursing Home Administrator, who acknowledged that the notification did not occur. The deficiency was cited under multiple Pennsylvania Codes related to the responsibility of the licensee, management, resident care policies, and nursing services.