Failure to Promptly Notify Conservator of Significant Change in Resident Condition
Penalty
Summary
The facility failed to promptly notify the conservator of a resident with severe cognitive impairment and a legal conservatorship of a significant change in condition involving an alleged sexual interaction. The resident, admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and anxiety disorder, was documented as having severely impaired decision-making capacity and was under the care of a conservator for healthcare decisions. On the date of the incident, the facility's records show that the physician was notified and a room change was ordered, but the conservator was not informed until the following day during a care conference. Interviews with facility staff revealed that the registered nurse on duty did not notify the conservator, believing the resident was self-responsible and able to understand the situation. However, both the Director of Nursing and the MDS nurse confirmed that the conservator was the designated healthcare decision-maker and should have been promptly notified according to facility policy. The delay in notification was acknowledged by the Director of Nursing, who stated that the conservator should have been called immediately following the change in the resident's condition.