Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's representative of a significant change in the resident's condition. The resident, who had diagnoses including right femur fracture, COPD, dementia, chronic kidney disease Stage IV, and pneumonitis, was admitted with severely impaired cognition and was dependent on staff for most activities of daily living. On the date in question, nursing documentation indicated the resident experienced a copious amount of rectal bleeding, and the on-call physician was notified, but no new orders were given. Despite this significant change in condition and subsequent transfer to the hospital for rectal bleeding, there was no documentation in the medical record to show that the resident's representative was informed of the event. The Director of Nursing confirmed during interview that there was no evidence of such notification and stated that the facility only had a policy for notifying physicians of changes in condition, not resident representatives.