Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative when there was a significant change in the resident's physical condition and a need to alter treatment. The resident, an elderly male with multiple complex diagnoses including acute kidney failure, muscle weakness, dysphagia, thrombocytopenia, gastrostomy status, sepsis, oral cavity carcinoma, diabetes type 2, atrial flutter, and deep vein thrombosis, experienced a change in condition characterized by shortness of breath and diarrhea. Orders were given for bowel rest, to hold tube feeding, obtain labs, provide nebulizer treatments as needed, and perform a chest x-ray. The chest x-ray revealed a small pleural effusion, and the physician ordered a course of antibiotics. There was no documentation that the resident's responsible party was notified of these changes, the x-ray, or the results. Interviews with the Director of Nursing (DON) and the Administrator confirmed that it was the facility's expectation and policy for nursing staff to notify the resident's representative of any change in condition, test orders, results, and new medication orders, and to document this notification in the electronic record. The facility's policies also required prompt notification of the resident's representative within 24 hours of a significant change in condition. Family members confirmed that they were not notified of the resident's change in status, x-ray, or results. The deficiency was identified through record review and interviews, with no evidence of notification to the responsible party documented.