Failure to Notify Physician or Representative of Resident Status Changes
Penalty
Summary
The facility failed to notify the physician or resident representative of changes in condition or status for three residents, as required by facility policy. For one resident with diabetes, PTSD, and hypotension, there was no documentation of physician or representative notification after the resident left the unit and was found near the front door by nursing staff. Another resident with hypertension, cancer, and hyperlipidemia was found on a different floor without the required monitoring device on their wheelchair, and again, there was no evidence of notification to the physician or representative regarding this incident. A third resident, who had high blood pressure, bilateral below-knee amputations, renal insufficiency, and severe cognitive impairment, had a new medication order for pantoprazole due to a history of gastrointestinal bleeding. The clinical record did not show that the resident's representative was notified of this medication change. Staff interviews confirmed that in all three cases, the required notifications to physicians or resident representatives were not made following changes in the residents' conditions or status.