Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding prompt notification of a resident's representative after a significant change in the resident's condition. A resident with multiple diagnoses, including type 2 diabetes, congestive heart failure, gout, chronic kidney disease, and morbid obesity, experienced shortness of breath and a drop in oxygen saturation to 87% after being transferred to bed with the assistance of four staff members. The LPN on duty assessed the resident and applied oxygen via nasal cannula but did not notify the resident's family representative of this change in condition, as required by facility policy. Documentation in the resident's electronic medical record and progress notes did not indicate that the family representative was informed, nor was there evidence that the physician or the Medical Director or DON were contacted when the physician did not respond. The DON later confirmed that the family representative had not been notified and that the LPN stated it had not occurred to her to do so. The facility's policy specifically requires prompt notification and documentation of such events, which was not followed in this instance.