Failure to Notify Responsible Parties and Providers of Changes in Condition
Penalty
Summary
Facility staff failed to notify residents' representatives and medical providers of significant changes in condition for two residents, resulting in harm. One resident with complex cardiac and renal conditions experienced a rapid and sustained weight gain, worsening edema, and shortness of breath over several days. Despite care plan instructions and hospital discharge orders requiring immediate physician notification for specific weight increases, there was no evidence that the cardiology physician was contacted. The resident's family was not informed of these concerning symptoms until the family member initiated contact, and the resident was ultimately sent to the hospital only after the family insisted, where she later expired. Another resident with multiple chronic conditions, including diabetes, chronic kidney disease, and heart failure, reported severe abdominal pain and vomiting over an extended period. Documentation and interviews revealed that the resident's pain and deteriorating condition were not promptly communicated to the Nurse Practitioner or the resident's Power of Attorney/daughter. The resident continued to experience pain and was not transferred to the hospital until many hours after the initial complaints, with the family only being notified shortly before the transfer. The delay in notification and treatment contributed to the resident's decline, and the hospital later determined the resident became septic due to a perforated ulcer. Interviews with staff and family members confirmed that communication failures occurred, with family members having difficulty reaching staff and not being informed of significant changes in the residents' conditions. Clinical records and care plans indicated that staff did not follow established protocols for timely notification of changes in condition to both medical providers and responsible parties, resulting in delayed interventions and harm to the residents.