Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
Nursing staff failed to notify the family of a resident with Crohn's Disease and Ulcerative Colitis when the resident experienced a significant change in condition, specifically an episode of bloody diarrhea. The resident, who was moderately cognitively impaired, was observed by the Nursing Supervisor during the morning shift with this acute symptom. The Nurse Practitioner was notified, and a voicemail was left for the resident's doctor, but there was no documentation that the resident's family was informed of the change in condition as required by facility policy. Interviews and medical record reviews confirmed that while the resident stated they had already called their son, there was no evidence in the medical record that staff had notified the family. The CNA reported that the resident's representative was present at the facility during the emergency, but again, no documentation supported that staff had made the required notification. The facility's policy mandates prompt notification of the resident's representative in the event of a significant change in condition, which was not documented in this case.