Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition for one resident with a history of cerebral palsy and an elevated white blood count. The resident began experiencing right eye pain, redness, and swelling, which progressed over two days. Nursing staff documented the symptoms, administered acetaminophen, and escalated the concern to the DON, who suspected cellulitis and contacted the nurse practitioner for further evaluation. A telemedicine visit confirmed preseptal cellulitis and conjunctivitis, and new medications were ordered, including oral antibiotics and antibiotic eye drops. Despite these developments, there was no documentation that the resident's representative was notified of the change in condition or the new medical interventions. Interviews with facility staff, including the ADON, LPN, and DON, confirmed that the resident's representative was not informed of the change in condition, and all acknowledged that notification should have occurred and been documented. The resident's representative expressed frustration at not being informed and stated she only learned of the situation during a visit. The resident also indicated a preference for having his representative notified of health changes. Review of the electronic health record and staff interviews confirmed the lack of notification and documentation, and the facility was unable to provide a policy regarding notification of changes in condition.