Failure to Notify Physician and Guardian After Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician and legal guardian following a significant change in the resident's condition. Specifically, a resident with severe cognitive impairment, cerebral palsy, seizure disorder, anxiety disorder, and a mental disorder, who had a legal guardian, was found to have pulled out their urinary catheter with the balloon still inflated, resulting in blood on the bed mat. Documentation in the resident's progress notes did not indicate that the urinary catheter was re-inserted, nor was there any record that the physician or the guardian was notified of this change in condition. The facility's policy requires staff to observe, record, and report any change in a resident's condition to the attending physician and responsible party to ensure appropriate treatment. During an interview, the DON confirmed that staff are expected to contact both the physician and guardian in such situations. However, in this instance, there was no evidence that these notifications occurred after the resident's condition changed.