Failure to Notify Responsible Party of Resident's Change of Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change of condition as required by policy. The resident, who had a cognitive communication deficit and aphasia, was admitted with severe cognitive impairment as indicated by a BIMS score of 0. On a specific date, a registered nurse documented that the resident's right big toe had a foul smell and planned to refer the resident to podiatry. However, during a subsequent review, both the Director of Nursing (DON) and the RN were unable to find documentation that the RP had been informed of this change in condition. The RN also could not recall notifying the RP about the issue with the resident's toe. Interviews with the DON confirmed that facility policy requires immediate notification of the physician and the RP in the event of a change of condition. Review of the facility's policy and procedure further supported this requirement, stating that residents, family, legal representatives, and physicians must be informed of significant changes in the resident's physical, mental, or psychosocial status. The lack of documentation and recall regarding notification resulted in the RP being uninformed and unaware of the resident's change of condition.