Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative of a change in condition for one of four residents reviewed. According to the facility's policy, the physician, resident, and family or responsible party are to be notified when an accident or incident involving a resident occurs. In this case, a resident with diagnoses of atrial fibrillation and dementia, and documented severe cognitive impairment, experienced a fall from his wheelchair. The incident report and clinical notes confirmed that the resident sustained a small injury to his forehead as a result of the fall. Despite the policy requirements, the resident's representative was not notified of the incident at the time it occurred. Documentation showed that the resident's wife only became aware of the fall after noticing a bruise on the resident's face during a visit to the facility, and was formally notified of the incident two days after it happened. The Nursing Home Administrator confirmed during an interview that the facility did not notify the resident representative of the change in condition as required.