Failure to Report and Document Changes in Resident Condition
Penalty
Summary
The facility failed to ensure that changes in a resident's condition were promptly reported to the physician, resident, and family as required by policy. A resident with multiple diagnoses, including dementia, COPD, and atrial fibrillation, was observed to have several changes in condition, such as visible bruising on the right hand, episodes of diarrhea, emesis, and a decline in oxygen saturation requiring supplemental oxygen. Despite these changes, there was no documentation in the medical record of timely notification to the physician or family regarding the bruising, diarrhea, or the need for oxygen administration. Surveillance video and staff interviews revealed that CNAs observed and provided care for the resident during episodes of incontinence and noted the resident voicing pain in her leg, but these concerns were not reported to nursing staff or documented. Nursing staff, including LPNs and RNs, either were not made aware of these changes or did not recall the events, and there was no evidence that the physician was notified about the resident's decline in oxygen saturation or the administration of oxygen. The physician later confirmed that he was not aware of the resident's emesis or oxygen use, and stated that protocol would have required further evaluation if he had been notified. Review of facility policies and job descriptions confirmed that staff were required to report changes in resident condition, including injuries, significant changes in physical status, and the need to alter medical treatment. However, the facility did not follow these protocols, as evidenced by the lack of timely communication and documentation regarding the resident's condition changes. This deficiency was identified through review of medical records, surveillance footage, and staff interviews.