Failure to Notify Resident Representative of Significant Change in Treatment Plan
Penalty
Summary
Facility staff failed to notify a resident's representative of significant changes in the resident's treatment plan, specifically regarding a scheduled and completed vascular intervention. The resident, who had severe cognitive impairment and multiple wounds related to peripheral artery disease, was evaluated by a physician and determined to require a right lower extremity angiogram with intervention. Documentation showed that the need for the procedure, its scheduling, and its completion were recorded in the medical record, but there was no evidence that the resident's representative was informed at any of these stages. The medical record indicated that the representative was notified when a new wound was first identified, but subsequent significant developments—including the scheduling of a vascular specialist appointment, the recommendation and scheduling of the angiogram with intervention, and the outcome of the procedure—were not communicated to the representative. The deficiency was identified during a complaint survey after the representative learned of the procedure through an insurance statement, rather than from facility staff.