Failure to Report Change in Resident Behavior
Penalty
Summary
The facility failed to report a change in behavior for one of three sampled residents. A certified nursing assistant (CNA) observed that the resident appeared more confused than usual and initiated a Stop & Watch notification, which is intended to alert staff to significant changes in a resident's condition. However, the CNA did not inform the charge nurse of these observed changes, and there was no documentation of a Stop & Watch notification in the resident's medical record or on the facility's dashboard. The Social Services Director was also not informed of any behavioral changes, and as a result, no referral to a psychologist or psychiatrist was made. The resident in question had a history of depression and anxiety disorder and was hospitalized for a urinary tract infection (UTI) following the observed change in behavior. The care plan for this resident included monitoring for changes in cognitive status and notifying the physician as needed. Despite these interventions being in place, the required notifications to the physician, resident, and resident representative were not made when the change in behavior occurred, as outlined in the facility's policy and procedures.