Failure to Notify Resident Representative of Change in Condition and Treatment Options
Penalty
Summary
The facility failed to notify a resident's legal representative of a significant change in condition, specifically regarding laboratory results and treatment options. The resident had a court-appointed guardian, with the guardian's spouse listed as the secondary emergency contact. On the date in question, a nurse received a urine culture result and sent it to the nurse practitioner. Occupational therapy evaluated the resident and determined that the resident was not safe to take anything orally except for minimal water for comfort. Based on this evaluation, the nurse attempted to contact the guardian to discuss the lab results and possible antibiotic treatment, leaving a voicemail but not successfully reaching the guardian. Subsequent documentation indicated that the nurse spoke with the guardian's spouse, who had questions about transferring the resident to another facility or hospital, but the nurse did not discuss the urine culture results or treatment options with the spouse, as they were not the legal guardian. During a later interview, both the guardian and spouse reported poor communication from the facility, including unreturned calls and a nurse hanging up during a call. The facility's policy requires notification of significant changes in condition or treatment to the resident's physician and representative, but the administrator confirmed that the guardian's spouse should have been updated about the positive lab results and treatment, which did not occur.