Failure to Notify Family or Responsible Party of Resident Condition Changes and Events
Penalty
Summary
The facility failed to ensure timely and documented notification to residents' families or responsible parties regarding changes in condition, falls, injuries, and new physician orders for multiple residents. Review of records for four residents revealed that staff did not document family or responsible party notification after significant events, including the initiation and discontinuation of antibiotics, multiple falls resulting in bruises or head injuries, and involvement in altercations. In each case, the residents' care plans specifically required staff to notify family and physicians of such changes, but there was no evidence in the progress notes that this communication occurred. For example, one resident with dementia and on hospice care received new and discontinued antibiotic orders for cellulitis, but there was no documentation that the family or responsible party was notified of these medication changes. Another resident, also with dementia and a history of repeated falls, experienced several falls resulting in bruises and head injuries, yet staff failed to document any notification to the family or responsible party after each incident. Similarly, a resident with COPD and diabetes was found at the foot of the bed, and another resident with dementia was involved in a physical altercation and a separate fall, but in both cases, there was no documentation of family notification. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the DON, and the Administrator, confirmed that the expectation was for nursing staff to notify families or responsible parties of any changes in condition, falls, or new orders, and to document this communication in the progress notes. However, the facility did not have a specific written policy regarding notification, and staff acknowledged that if notification was not documented, it was considered not done. The lack of documentation and failure to notify families or responsible parties as required by care plans and resident rights constituted the deficiency.