Failure to Notify Responsible Party and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The facility failed to notify a resident's responsible party (RP) and physician of significant changes in the resident's condition and treatment. Specifically, there was no documentation that the RP was notified when the resident's urinary catheter was found removed with the balloon intact, when antibiotic therapy was changed from IV via PICC line to oral administration, and when the PICC line became clogged and unusable. Additionally, the physician was not notified of missed IV antibiotic doses and refused medications. These failures were identified through record review and interviews with staff and the RP. The resident involved was an elderly female with multiple complex medical conditions, including sepsis, a recent femur fracture, dementia with behavioral disturbance, Alzheimer's disease, and a surgical wound requiring specialized care. She was dependent on staff for activities of daily living, had impaired mobility, and was at risk for pressure injuries. The resident had a history of pulling out medical devices, including her PICC line and urinary catheter, and required high-risk medications and special treatments such as IV antibiotics and wound therapy. Nursing notes and interviews revealed that staff did not consistently notify the RP or physician of these significant events. For example, when the resident pulled out her PICC line and catheter, there was no documentation of RP notification. When the PICC line became clotted and IV antibiotics were missed or changed to oral, the RP was not informed at the time of the change. Staff interviews confirmed that notification did not occur as required, and the facility's own policy and INTERACT tool indicated that such notifications should have been made and documented.