Failure to Notify Emergency Contact of Change in Condition
Penalty
Summary
The facility failed to ensure that a resident's emergency contact was notified of a change in condition. Medical record review showed that the resident's father, who was listed as the primary emergency contact, had passed away in 2022, but the chart was not updated to reflect this. As a result, no family member was notified when the resident experienced a significant change in condition. The resident, who had multiple diagnoses including ataxic cerebral palsy, epilepsy, anemia, thoracic aortic aneurysm, schizophrenia, obsessive compulsive disorder, and major depressive disorder, required assistance with activities of daily living and personal care. Progress notes indicated that a urinalysis with culture and sensitivity was ordered without documentation of the reason, the ordering provider, or family notification. Additionally, late entry notes were made regarding antibiotic use, but these were completed a month after the events occurred, and there was no evidence of timely documentation or family notification. On one occasion, a registered nurse found the resident unresponsive and, after consulting with a physician and nurse practitioner, the resident was sent to the hospital. The nurse practitioner attempted to contact the family but received no response. Interviews with facility staff confirmed that the emergency contact information was outdated and that there was no documentation of family notification regarding the resident's change in condition or new medical orders. The facility's policy required notification of resident representatives or authorized family members for changes in condition, but this was not followed in this case.