Failure to Notify Physician and Family of Significant Behavioral Changes and Transfer
Penalty
Summary
The facility failed to notify the physician, guardian, and emergency contact of a resident's significant behavioral episodes as required by policy. Record reviews showed that the resident, who had multiple psychiatric diagnoses including bipolar disorder with psychotic features, anorexia nervosa, and major depressive disorder, experienced several episodes of screaming, flailing, hitting, and combative behavior. On one occasion, an LPN was notified by a nurse aide about the resident's episode and administered Zyprexa IM twice during the shift but did not notify the physician, family, or guardian about the incident. Interviews confirmed that the guardian and emergency contact were not informed of these behavioral changes or the subsequent transfer to a hospital until after the events occurred. Facility policy requires prompt notification of the resident, physician, and representative in the event of significant changes in condition, including behavioral deterioration or transfer to another facility. Interviews with facility leadership confirmed that the nurse should have contacted the physician, guardian, and emergency contact regarding the behavioral episodes and transfer. Documentation and interviews with the resident's contacts further confirmed that required notifications were not made in accordance with policy.