Failure to Notify Family of Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely notification of a change in condition to a resident's family representative, as required by policy. A resident with severe cognitive impairment and multiple diagnoses, including dementia, anemia, and systemic lupus erythematosus, was observed by their family representative to have redness in the right eye. The family representative reported this observation to facility staff and was informed that the redness was due to an allergic reaction and had already been addressed by the physician. However, there was no documented evidence that nursing staff had identified, assessed, or reported the redness prior to the family representative's observation. Further review revealed that ciprofloxacin ophthalmic drops were ordered for the resident's right eye without a documented assessment or clear reason for the order. Interviews with facility staff confirmed that the family representative was the first to identify and report the change in the resident's condition, and that staff had not notified the family representative of the issue prior to their visit. The nurse supervisor admitted to initiating the antibiotic order in response to the family representative's concerns, without completing or documenting a nursing assessment beforehand.