Failure to Notify Responsible Party and Dietician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party and the Registered Dietician (RD) of a significant change in a resident's condition, specifically regarding ongoing refusals of meals and medications. The resident, who had a history of hypertension, cognitive impairment, dysphagia, chronic kidney disease, and recent abnormal weight loss, began refusing meals and medications over several days. Documentation showed that the resident consumed less than 25% of meals or refused them entirely on multiple occasions, and also refused several doses of prescribed medications. Despite these changes, there was no documentation that the resident's representative or the RD were informed of the ongoing refusals and significant change in status. Staff interviews confirmed that the resident's behavior of refusing meals and medications was new and represented a significant change from previous patterns. The LPN stated that refusals were documented and the physician was notified, but the RD was not informed. The RD herself confirmed she was unaware of the refusals and would have reassessed the resident's nutritional plan had she been notified. The resident's representative also reported not being informed about the refusals and was unaware of the change in the resident's condition until contacted by surveyors. Facility policy required prompt notification of the resident, physician, and representative of significant changes in condition, including those requiring alterations in treatment. However, interviews with staff, including the MDS RN, Infection Preventionist/Unit Manager, DON, and Administrator, revealed inconsistent understanding and application of these policies. The lack of notification to the RD and responsible party was not documented, and staff acknowledged the importance of such communication but failed to ensure it occurred in this case.