Failure to Notify Responsible Party of Resident Falls and Change in Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's falls, change in condition, and transfer to the emergency department, as required by facility policy. The resident, who was moderately cognitively impaired and unable to make healthcare decisions, experienced four unwitnessed falls, a dislodged indwelling catheter that was not replaced, and a significant change in condition due to a possible head injury. Despite documentation indicating that the resident's daughter was to be notified of any changes, there was no evidence that the RP was informed of these incidents in a timely manner. Record review showed that nursing staff repeatedly documented the resident as her own RP, even after social services noted that the daughter should be contacted for healthcare decisions. Progress notes for each fall and the catheter incident either incorrectly listed the resident as her own RP or lacked documentation of RP notification. When the resident was transferred to the emergency department for further evaluation after a change in condition, the daughter was not contacted until several hours after the transfer, and only a voicemail was left. Interviews with staff confirmed confusion regarding who was the appropriate RP, and the DON acknowledged that the daughter had requested to be notified of any changes but was not. The lack of timely and accurate notification to the RP prevented the family from being aware of the resident's condition changes and participating in care decisions, as required by facility policy.