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F0580
D

Failure to Notify Provider of Resident's Change in Mental Status

Havre De Grace, Maryland Survey Completed on 11-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely notification to a physician regarding a resident's change in condition. Specifically, a resident was observed by a registered nurse to be tearful and experiencing increased confusion, which was also documented by a social worker. Despite these documented changes in the resident's mental status, there was no evidence in the medical record that the provider was notified of the change. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that such changes should be communicated to the provider and documented, but no such documentation or notification was found for this incident.

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