Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative (RP) of a significant change in the resident's condition when the resident was found with a removed midline IV from his left arm, resulting in the need for his arm to be elevated and wrapped to manage swelling and bleeding. The resident, an elderly male with severe cognitive impairment and multiple serious diagnoses including atherosclerotic cardiovascular disease, chronic kidney failure, dementia, and malignant brain neoplasm, was noted to have a new skin tear and abnormal skin findings following the incident. Documentation showed that while the physician and a family member (FM) were informed, the RP was not notified at the time of the incident. Interviews with facility staff, including nurses and administrative personnel, confirmed that the standard protocol was to notify the RP of any change in condition. However, in this case, the nurse involved informed the FM who was visiting, but did not contact the RP directly. The nurse acknowledged that this was not in line with facility policy, which requires direct notification of the RP regardless of whether a family member is present or informed. The RP only learned of the incident later, when contacted about the possibility of inserting a new midline IV. Further interviews with clinical and administrative staff reiterated the expectation that the RP should be notified as soon as possible in the event of a change in condition. The facility's policy, revised in April 2025, also specifies that the resident or their representative must be informed of any change in condition and related changes in care. The failure to notify the RP promptly was confirmed by both staff statements and documentation review.