Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's designated representative of significant changes in the resident's condition, as required by facility policy. The policy states that the responsible party must be informed of any change in the resident's condition and the steps being taken, with all attempts at notification documented in the nursing progress notes. However, record review and interviews revealed that the representative was not notified of several notable changes, including facial swelling, an urgent dental visit, leg edema, loose stools, and bruising on the knee and face. The resident involved was cognitively impaired, with a BIMS score of zero, and required maximal assistance with daily activities. The medical record showed multiple incidents: a limp and mild bruising on the left knee, facial swelling and dental issues requiring urgent referral, right periorbital ecchymosis, and episodes of loose stools and leg edema. In each case, there was no documentation that the resident's representative was informed of these changes or the interventions ordered by physicians, despite the facility's policy and the resident's inability to communicate his needs. Interviews with staff, including RNs and regional clinical resources, confirmed that bruising, black eye, edema, and loose stools are considered changes of condition that require notification of the physician, DON, and the resident's representative. Staff acknowledged a gap in documentation regarding who was notified when a change of condition occurred. The resident's representative also reported not being informed about these significant health events, emphasizing the importance of communication due to the resident's inability to advocate for himself.