Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition, as required by facility policy. Specifically, the resident experienced poor oral intake, refused meals and fluids, exhibited increased weakness, was sleepy, and showed increased confusion on 8/3/25. Despite these changes, there was no documented evidence in the closed medical record that the resident's family member or representative was informed of these developments. The facility's policy mandates prompt notification of the resident, physician, and representative in such situations, especially when the resident may not be able to communicate these changes personally. Interviews with facility staff, including an LVN and the DON, confirmed that the resident's representative was not notified following the change in condition. The LVN acknowledged that both the physician and family member should have been informed after the change was identified. The deficiency was identified through interviews, closed medical record review, and review of the facility's policies and procedures.