Failure to Immediately Notify Resident Representative After Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative (RP) following a significant change in the resident's condition. The resident, an elderly female with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Alzheimer's Disease, experienced a sudden decline on the morning of 08/14/25, including abnormal vital signs, decreased intake, functional decline, decreased level of consciousness, low-grade fever, shortness of breath, non-productive cough, abnormal lung sounds, and cold symptoms. Her oxygen saturation was measured at 82%, and she was administered oxygen via nasal cannula as per physician orders. The change in condition evaluation was completed by the ADON, who documented that the physician was notified on the same day. However, the RP was not notified of the resident's change in condition until a week later, as indicated in the documentation and confirmed by interviews with the RP, ADON, and DON. The RP only learned of the incident after requesting medical records following the resident's discharge. The facility's policy requires immediate notification of the resident, physician, and representative in the event of a significant change in condition, but this protocol was not followed in this instance.