Failure to Notify Provider of Resident's Change in Behavior
Penalty
Summary
A deficiency occurred when staff failed to notify the provider of a resident's significant change in behavioral symptoms. The resident, who had diagnoses including dementia with behavioral disturbances, anxiety, major depressive disorder, emphysema, and congestive heart failure, exhibited new and escalating angry outbursts and agitation over several days. These behaviors included throwing linens, screaming at staff, and throwing fluids, which were not part of the resident's documented baseline behavior. Despite these changes, there was no evidence that the nursing supervisor or provider were notified at the time the behaviors were first observed. The clinical record review showed that prior to these incidents, the resident had not exhibited similar angry outbursts. Staff attempted to redirect the resident but did not escalate the issue or seek provider input, even though the resident was unable to be redirected and had no available as-needed medication to address the agitation. The behaviors were only documented in a psychiatric APRN book, with no immediate notification to supervisory staff or the provider, contrary to facility policy which required provider notification for significant changes in condition. Interviews with staff confirmed that the provider should have been notified of the resident's behavioral changes, as these were not consistent with the resident's baseline and could have indicated an underlying medical issue. The delay in notification meant that potential interventions, such as ordering laboratory tests or adjusting medications, were not initiated in a timely manner. Facility policy also required documentation of provider and family notification, which was not completed at the time of the initial behavioral changes.