Failure to Notify Responsible Party and Document Change in Condition
Penalty
Summary
The facility failed to ensure the clinical record for a resident with severe cognitive impairment and chronic health conditions was complete and accurate, specifically regarding timely notification of a change in condition to the court-appointed Conservator of Person (COP). The resident developed red, irritated eyes, and a physician ordered Artificial Tears to be administered. However, there was no documentation that the COP was notified of the resident's eye condition or the new medication order. Subsequently, the COP requested hospital evaluation, where the resident was diagnosed with conjunctivitis and prescribed antibiotic eye drops. Upon the resident's return from the hospital, there was again no documentation that the COP was notified of the new diagnosis or the new medication orders. Interviews with facility staff, including the APRN, RN, ADNS, and DNS, confirmed that the COP should have been notified and that such notifications should have been documented in the medical record, but this was not done. The facility's policy required notification and documentation of changes in condition and new orders, but this was not followed in this case.