Failure to Notify Guardian of Resident's Change in Condition and Diet
Penalty
Summary
The facility failed to notify the legal guardian of a resident regarding significant changes in the resident's condition and dietary requirements. The resident, who had multiple diagnoses including osteoarthritis, bipolar disorder, type II diabetes, atherosclerosis, and dementia, experienced a decline in condition and a change in diet following a hospital stay. The guardian was listed as the primary emergency contact and responsible party in the resident's records, with contact information clearly documented. Despite this, there was no documentation in the electronic medical record indicating that the guardian was informed of the resident's decline or the change to a puree diet. Interviews with facility staff, including the DON and Social Services Director, revealed that the guardian was not notified of these changes and that staff were unclear about the notification process. The DON stated that the nurse involved did not know who the guardian was and instead notified the resident's grandson. The guardian confirmed during an interview that he was not made aware of the resident's change in condition or diet, and expressed concern about the lack of communication regarding these significant changes.