Failure to Notify Guardians of Significant Resident Events
Penalty
Summary
The facility failed to notify the legal guardians of two residents regarding significant changes in their conditions and events affecting their care. In the first case, a resident with a history of psychiatric disorders, cognitive impairment, and a legal guardian was admitted and immediately expressed a desire to leave the facility. Although the guardian was initially contacted and advised staff to calm the resident and use an involuntary psychiatric hold if necessary, the resident was later allowed to sign out on a leave of absence (LOA) without further consultation with the guardian. The resident left the facility, returned later with police escort, and the guardian was not notified of either the departure or the return in a timely manner. Documentation showed that the guardian would have imposed restrictions on LOA if consulted, and staff did not notify the guardian as required by policy. In the second case, another resident with ataxic cerebral palsy, epilepsy, schizophrenia, and a legal guardian was sent to the hospital after being found unresponsive. The facility's records had not been updated to reflect the current legal guardian, as the previous guardian had passed away. Nursing staff attempted to contact the deceased guardian and only later tried to reach the correct guardian, but no voice message was left. The nurse practitioner also attempted to contact the guardian but could not recall if a message was left and stated a preference not to leave messages that might cause panic. There was no documentation of successful notification to the legal guardian regarding the resident's hospitalization. Facility policy required prompt notification of guardians or responsible parties in the event of significant changes, such as hospitalization or LOA. In both cases, the facility did not follow its own policies for notification, resulting in guardians not being informed of critical events affecting the residents. The deficiencies were identified through medical record review, staff and guardian interviews, and policy review, affecting two of the 22 residents reviewed for notification.