Failure to Notify Responsible Party of Change in Resident Status
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) of a resident following a significant change in the resident's status. Specifically, a female resident with severe cognitive impairment and multiple medical diagnoses, including dementia, was found lying in bed with a male resident in a room that did not belong to either of them. The male resident, who also had dementia and other neurological and medical conditions, was fully clothed and had his hand on the female resident's leg. The incident was documented by an LVN, who redirected the male resident and notified the Director of Nursing (DON), but did not recall notifying the responsible parties for either resident. Review of the female resident's records showed no documentation of the incident or notification to her RP on the date it occurred. The care plan for the female resident included interventions to ensure family and physician awareness of behaviors or changes, but there was no evidence these were followed in this instance. Similarly, the male resident's care plan, updated after the incident, included interventions for sexually inappropriate behavior and required family and physician notification of such behaviors, but there was no documentation that this occurred for the incident in question. Interviews with facility staff and the administrator confirmed that the incident was not reported to the responsible parties as required. The administrator stated she was unaware of the incident and expected immediate notification to both herself and the residents' RPs. The family member for the female resident reported only being notified of a later incident and expressed concern about not being informed of the earlier event. Facility policy requires notification of changes in condition or incidents affecting residents, but this was not followed in this case.