Failure to Notify Resident Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to ensure that a resident's Power of Attorney for Healthcare (POAHC) was notified of significant changes in the resident's condition and treatment. The resident, who had diagnoses including quadriplegia, diabetes mellitus type 2, and a stage 4 sacral pressure ulcer, was found to have yeast in the urine and was prescribed an antifungal medication. Although the POAHC was informed that a urinalysis and urine culture would be performed, there was no documentation that the POAHC was notified of the test results or the initiation of antifungal treatment. The POAHC confirmed not being informed about the results or the new medication order, only learning of further developments when the resident was transferred to the hospital after becoming unresponsive. Additionally, the resident experienced multiple episodes of low blood pressure over two consecutive days. The facility's policy and standing orders required that the physician and the resident's representative be notified of such significant changes, especially when blood pressure readings fell below specified thresholds. However, there was no evidence in the medical record that either the physician or the POAHC was notified of these low blood pressure readings. Interviews with facility staff confirmed that these notifications did not occur, and staff acknowledged that such notifications should have been made. The facility's own policy, revised shortly before the incident, required prompt notification of the resident, physician, and representative in the event of significant changes in condition or treatment. Despite this, documentation and interviews revealed that the required notifications were not consistently made or documented, particularly regarding the new infection, treatment, and episodes of low blood pressure. The deficiency was identified through record review and interviews with the POAHC and facility staff.