Failure to Notify Representatives of Changes in Condition and Treatment
Penalty
Summary
The facility failed to notify residents' representatives of significant changes in condition or treatment for two residents. In the first case, a resident with a gastrostomy tube had their feeding method changed from infusion via pump to bolus administration by the dietitian to accommodate the resident's preference for being out of their room. The clinical record did not contain documentation that the resident's representative was informed of this change. Both the LPN Unit Manager and the DON confirmed that the representative should have been notified at the time of the order change, but this did not occur. In the second case, a resident with a Stage 4 pressure ulcer on the coccyx experienced a worsening of the wound, as evidenced by increased measurements in length and width. Despite this change in condition, there was no documentation in the medical record that the resident's representative was notified of the deterioration. The DON confirmed that notification was not completed for this change in the resident's condition.