Failure to Notify Responsible Party After Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party after a significant change in the resident's condition that required an alteration in the treatment plan. Specifically, a resident with a history of stroke, hemiplegia, hemiparesis, an open wound from a left breast biopsy, and seizures experienced dehiscence of the surgical area on the left breast. The physician and nurse manager were notified, and new orders for antibiotics and wound care were implemented. However, there was no documentation that the resident's representative was informed of this change in condition or the new treatment until several days later. Interviews with facility staff confirmed that the nurse on duty contacted the physician but did not notify the family as required by facility policy. The resident's family only became aware of the situation after being informed by the resident, at which point they contacted the facility and requested hospital follow-up. Facility leadership stated that staff are expected to notify family members as soon as possible after a change in condition, and definitely before the end of their shift, but this did not occur in this instance.