Failure to Notify Resident's Representative After Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's designated representative of a significant change in the resident's condition, specifically following a fall. According to the facility's policy, staff are required to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there is an accident or significant change in status. In this case, the resident, who had a history of falls and multiple medical conditions including stroke, acute respiratory failure, and osteoarthritis, experienced a fall during the night. The nurse's progress note documented the fall, the resident's condition, and that the physician was notified, but there was no documentation that the resident's representative was informed at that time. The resident's representative later reported not being notified of the fall until the resident was transferred to the hospital after becoming unresponsive, approximately eight hours after the incident. The representative expressed frustration and distress over not being informed promptly, especially as she was the resident's power of attorney and had previously communicated her expectation to be notified at any time, including during the night. Hospital records indicated the resident had a large subdural hematoma and was placed on hospice care, passing away four days later. Interviews with staff, including LPNs, RNs, and the DON, confirmed that the facility's protocol was to notify the resident's representative immediately after a fall, regardless of the time, unless otherwise care planned. However, in this instance, the notification was delayed until after the resident's condition had significantly deteriorated and he was transferred to the hospital. The DON acknowledged the delay and lack of awareness regarding the representative's wishes for immediate notification.