Failure to Notify Health Care Agent of Resident Condition Changes and New Orders
Penalty
Summary
Nursing staff failed to notify the Health Care Agent (HCA) of a resident with an activated Health Care Proxy about significant changes in the resident's condition and new physician orders. The facility's policy requires prompt notification of the resident's representative regarding changes in medical or mental condition, and documentation of such notifications in the medical record. However, the HCA was not informed of the resident's re-admission from the hospital, a new diet order, the presence of a blister on the right heel, or a vasovagal episode that resulted in new physician orders for lab work. The resident, who had diagnoses including dementia, bipolar disorder, diabetes, Parkinson's disease, hypertension, and hyperlipidemia, was re-admitted to the facility after hospitalization. Upon return, the resident required a dysphagia diet and had a fluid blister on the right heel, for which new treatment orders were obtained. Documentation showed that the diet requisition form was not completed until several days after re-admission, and there was no evidence that the HCA was notified of these changes. Additionally, the resident experienced an episode of unresponsiveness while with therapy, leading to further physician orders, but again, there was no documentation of HCA notification. Interviews with nursing staff and facility leadership confirmed that the HCA was not notified of the resident's condition changes or new orders, despite facility policy and expectations. The HCA only became aware of the incidents and changes after independently requesting and reviewing the resident's medical record. There was no documentation in the medical record to support that the required notifications were made to the HCA regarding the resident's new diet, treatment orders, or significant health events.