Failure to Notify of Significant Change in Condition and Poor Intake
Penalty
Summary
Facility staff failed to notify the Nurse Practitioner and the resident's Responsible Party immediately of a significant change in condition for a resident with complex medical needs. The resident, who had severe cognitive impairment and was dependent for most activities of daily living, experienced a decline in urinary output and fluid intake. Despite multiple alerts in the electronic medical record indicating poor meal intake and documented low urostomy output, there was no evidence that the medical provider or the Responsible Party was notified of these changes. The clinical record also lacked documentation of fluid intake monitoring, even though the resident was at risk for dehydration and had a history of poor intake upon admission. Interviews with facility staff revealed that poor intake was considered the resident's baseline, and as such, changes were not reported to the Nurse Practitioner or Responsible Party. The Registered Dietician and nursing staff did not consistently monitor or communicate the resident's nutritional and hydration status, and the facility did not implement daily fluid intake measurements despite ongoing concerns. The Director of Nursing acknowledged that monitoring should have occurred and that it was the nurses' responsibility to notify the medical provider and family of any change in condition, including poor intake. The resident's Responsible Party had previously voiced concerns about dehydration and requested increased nutritional support and monitoring, but there was no evidence that these interventions were consistently implemented or communicated. Ultimately, the resident experienced a rapid decline, prompting emergent notification and transfer to the emergency room. The clinical record and staff interviews confirmed that significant changes in the resident's condition were not promptly communicated to the medical provider or Responsible Party as required.