Failure to Notify Practitioners and Representatives of Resident Changes and Incidents
Penalty
Summary
The facility failed to notify practitioners and resident representatives of significant changes in condition and incidents involving multiple residents, as required by policy and regulation. For one resident with multiple complex diagnoses including diabetes, end stage renal disease, and dementia, staff did not inform the practitioner of increased lethargy, decreased appetite, low blood glucose levels, and the withholding of insulin doses due to poor intake. Documentation showed that over a 24-hour period, the resident was lethargic, refused or was unable to eat, and required increased assistance, yet there was no evidence of practitioner notification regarding these changes or the missed insulin administration. For two other residents with histories of falls and significant medical conditions, the facility did not consistently notify either the practitioner or the resident's representative following falls or changes in condition. In one case, a resident experienced multiple falls, some with injury, and episodes of slurred speech and unresponsiveness, but there was no documentation that the family or practitioner were notified as required. In another case, a resident was found on the floor after a fall and, on a separate occasion, experienced a fall due to an unlocked wheelchair; in both instances, either the physician or the family was not notified as per policy. Interviews with the DON confirmed that charge nurses were responsible for these notifications and acknowledged that required notifications were not made in several instances. The facility's own policies stipulated immediate notification of practitioners and representatives following significant changes or incidents, but these procedures were not followed for the residents involved.