Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of two significant changes in the resident's condition. According to interviews and record review, the resident, who had been determined by a physician to lack capacity due to Alzheimer's disease, experienced two separate incidents: one involving an elevated pulse/heart rate while resting, and another involving altered mental status, weakness, shortness of breath, nausea, vomiting, and lethargy. In both cases, the resident remained in the facility and was treated in-house by on-call physicians, but the representative was not informed of these events. The resident's representative reported not being contacted by the facility regarding either incident and expressed distress over the lack of communication. Review of facility policy confirmed that the representative should have been notified immediately of significant changes in the resident's physical or mental status. The Director of Nursing and the Administrator acknowledged that the notifications should have occurred.