Failure to Notify Physician and Conservator After Abuse Allegation
Penalty
Summary
The facility failed to notify both the attending physician and the resident's conservator after a resident made an allegation of abuse. The resident, who had a history of nontraumatic chronic subdural hemorrhage, schizophrenia, and depression, and was assessed as lacking the mental capacity to make decisions, reported to a nurse that he had been hit by staff and claimed to have scratches and bruises on his arm. The nurse assessed the resident and found no evidence of injury, and subsequently documented the incident in the progress notes but did not inform the physician or the conservator. The nurse determined that the allegation was not credible based on the resident's history of fabricating stories and did not consider it a change in condition. The Director of Nursing confirmed that the facility's policy required notification of the physician and the resident's representative in the event of an abuse allegation or change in condition. The failure to notify the physician delayed any potential medical or psychiatric evaluation, and the conservator was not made aware of the resident's well-being. Facility policies and performance improvement plans reviewed indicated that such notifications were required, but these procedures were not followed in this instance.