Failure to Notify Responsible Party of One-to-One Monitoring Assignment
Penalty
Summary
The facility failed to inform a resident's responsible party about the initiation of one-to-one monitoring for a resident who was unable to make their own medical decisions. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and was assessed as severely cognitively impaired and unable to make decisions. The resident was identified as being at risk for elopement, had previously worn a wander guard, and had removed the device, refusing its reapplication. As a result, staff began one-to-one monitoring to ensure the resident's safety. Despite this significant change in the resident's care, there was no documentation or evidence that the responsible party was notified about the implementation of one-to-one monitoring. Interviews with facility staff, including the Director of Staff Development, a Registered Nurse, and the Director of Nursing, confirmed that the responsible party was not informed of this intervention. The responsible party also stated during an interview that neither she nor the former responsible party had been notified about the one-to-one sitter assignment, learning about the removal of the wander guard only through another family member. Facility policy required that family members or responsible parties be notified of any change in condition, with documentation of the notification in the nurses' notes. The care plan and physician's orders did not reflect the one-to-one sitter intervention, and there was no record of communication to the responsible party regarding this change. This omission constituted a failure to uphold the resident's right to have their representative informed of significant changes in treatment and services.