Failure to Notify Physician and Resident Representatives of Change in Condition
Penalty
Summary
The facility failed to notify the physician and the resident's representatives of significant changes in a resident's condition and status. The resident in question had multiple diagnoses, including type 2 diabetes mellitus, unspecified psychosis, severe protein-calorie malnutrition, and dementia with agitation, and was noted to have severely impaired cognition. Documentation in the medical record showed that the resident experienced episodes of sedation, lethargy, and required assistance with feeding and medication administration. On several occasions, nursing staff documented that the resident was sedated, medications were held, and the resident's condition deviated from their baseline. Despite these changes, there was no documented evidence that the resident's representatives or the physician were notified of the resident's altered condition, including when the resident was sedated, medications were withheld, or when there were changes in medication orders. The facility's own policy required prompt notification of the resident, physician, and resident representative in the event of significant changes in condition or treatment, such as deterioration in health or the need to alter treatment due to adverse consequences. However, the medical record lacked documentation of such notifications during the periods when the resident's condition changed. Interviews with the Director of Nursing confirmed that the expectation was for nursing staff to notify the resident's representatives and physician of any significant change in condition, including lethargy or sedation outside the resident's norm, and to document this communication. The surveyors found no additional information or documentation to indicate that the required notifications had occurred, confirming the deficiency in following notification protocols as outlined in facility policy and regulatory requirements.