Failure to Immediately Notify Physician and Representative of Significant Resident Changes
Penalty
Summary
The facility failed to immediately inform residents, their representatives, and physicians of significant changes in residents' physical, mental, or psychosocial status, as required by policy. In one case, a male resident with severe cognitive impairment, major depressive disorder, anxiety disorder, unspecified dementia, and Alzheimer's disease exhibited combative behavior, broke a window, and required intervention from police, EMS, and hospice staff. Despite these significant behavioral changes and the administration of Haldol, the resident's primary physician and power of attorney (POA) were not promptly notified by facility staff. The POA was only informed after the incident by a hospice nurse, and the primary physician was not notified until days later by the DON. Documentation and interviews confirmed that the facility staff did not follow the care plan interventions for notification and failed to communicate the events in a timely manner. In another instance, a male resident with severe cognitive impairment, dementia, and multiple cancer diagnoses developed a Stage 3 pressure ulcer. Nursing staff identified the wound and notified wound care, but failed to notify the resident's primary physician and POA of the significant change in health status. The nurse responsible admitted to being too busy to make the notifications and did not document any attempt to contact the responsible party. The primary physician and wound care physician both confirmed they were not informed of the pressure ulcer until after the fact, and the responsible party was not reached or left a message. Facility policy requires immediate notification of the resident, physician, and representative in the event of significant changes, injuries, or the need to alter treatment. Record review and interviews revealed that these requirements were not met in the cases reviewed, resulting in a lack of timely communication regarding significant changes in residents' conditions and treatment regimens. The failure to notify could have prevented residents from receiving timely and needed treatment, as acknowledged by staff during interviews.