Failure to Notify Responsible Parties of Resident Condition Changes and New Orders
Penalty
Summary
The facility failed to ensure that residents' responsible parties or emergency contacts were notified of changes in condition and new physician orders, as required by facility policy and standard practice. For three residents, staff did not document notification to responsible parties regarding significant health events, new medication orders, or changes in care. The facility's own medication order policy required staff to notify the resident's sponsor or family of new medication orders, but there was no documented policy related to notifications of resident change in condition to responsible parties or family members. One resident with multiple diagnoses, including encephalopathy, COPD, and bipolar disorder, experienced several health events such as shortness of breath, new antibiotic and insulin orders, and requests for palliative or hospice care. In each instance, staff failed to document that the responsible party was notified of these changes. Another resident with diabetes, COPD, and a traumatic amputation had incidents including a reported fall, new wounds, and new antibiotic orders, but staff did not document notification of the responsible party regarding these events or new treatments. A third resident with severe cognitive impairment and multiple chronic conditions had changes in urinary output, new catheter and antibiotic orders, and behavioral medication changes, with no documentation of responsible party notification. Interviews with staff, including CNAs, CMTs, LPNs, the DON, and the Administrator, confirmed that the expectation was for nursing staff to notify family or responsible parties of changes in condition and new orders, and to document these notifications. However, review of the medical records for the three residents showed repeated failures to document such notifications, even when significant changes or new orders occurred. Additionally, there were issues with accessing care plans in the electronic medical record for two residents, further complicating the ability to ensure proper communication and documentation.