Failure to Notify Physician and Update Care Plan After Resident's Reported Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for one of three sampled residents after the resident reported being struck and expressed fear, indicating a psychosocial change. The resident, who had a history of major depressive disorder and moderate cognitive impairment, reported to the ombudsman that an unknown black male struck him in the stomach. The incident was communicated to facility staff, including an LVN, RNS, and the DON, but there was no documentation of physician notification or care plan review and update in response to the reported allegation. Interviews with staff revealed that the LVN did not notify the physician or document the incident, believing it was unnecessary due to the resident's history of making similar statements. The RNS and DON both acknowledged that a report of being struck and expressing fear constitutes a change in condition, including a psychosocial change, and that facility policy requires physician notification, documentation, and care plan review and update. However, these actions were not taken for the resident in question. A review of the resident's psychological consultation indicated ongoing feelings of unsafety and persecution based on race. The facility's policy and procedure on changes in a resident's condition or status requires prompt notification of the resident, attending physician, and representative of changes in medical or mental condition. Despite this, the required notifications and documentation were not completed following the resident's report of being struck and expressing fear.