Failure to Notify Resident Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure that resident representatives were notified of significant changes in condition for two of four sampled residents. For one resident with diagnoses including congestive heart failure and obstructive sleep apnea, documentation showed that the physician was notified and new medications were ordered following complaints of nausea and an elevated A1C level, which led to a new diagnosis of type II diabetes mellitus. However, there was no documentation that the resident's representative was informed of the new medications, abnormal laboratory results, or the new diagnosis. The resident's representative confirmed limited contact from the facility since admission. For another resident with diabetes mellitus and muscle weakness, a nurse note indicated that after a fall from the bed, the physician, DON, and family member were reportedly notified. However, the family member stated they were not informed of the fall. Interviews with nursing staff revealed inconsistent understanding of when to notify resident representatives, particularly for cognitively intact residents, with some staff believing notification was not always necessary unless requested by the representative.