Failure to Notify Physician of Resident's Significant Behavioral Change
Penalty
Summary
The facility failed to notify the attending physician of a significant behavioral change in a resident, as required by policy. The resident, who had a history of Parkinsonism, muscle wasting, quadriplegia, and depression, exhibited new aggressive behaviors on the date in question, including scratching and drawing blood from a staff member during an altercation. Prior to this incident, the resident had expressed a desire not to be cared for by a particular CNA and had requested to wait for the next shift for personal care, but these requests were not honored. The resident became agitated and physically aggressive when staff proceeded with care despite her objections. Multiple staff interviews confirmed that the resident's behavior during the incident was a new development, with the administrator specifically stating that scratching and drawing blood from staff was not a previously documented behavior for this resident. The care plan for the resident included monitoring for behavioral changes and notifying the physician if significant changes occurred. However, despite the escalation and physical aggression, there was no documentation or evidence that the physician was informed of this change in condition. The facility's policy required prompt notification of the physician and the resident's representative in the event of a significant change in the resident's physical, mental, or psychosocial status. The administrator acknowledged that a change of condition (COC) should have been created and the physician notified to address the new behavioral issue, but this did not occur. As a result, there was a failure to follow established procedures for physician notification in response to a significant behavioral change.