Failure to Notify Resident's Representative and Hospice of Significant Changes
Penalty
Summary
The facility failed to notify a resident's representative (RP) and hospice agency of multiple significant changes in the resident's condition, including falls, bruising, behavioral changes, and medication changes. Documentation revealed that the resident, who had a history of cerebral infarction, hemiplegia, Alzheimer's disease, repeated falls, and was receiving hospice services, experienced several incidents such as sliding or rolling out of bed, developing new bruises, and exhibiting increased agitation and behavioral changes. Despite these events, there was no documentation that the RP or hospice agency were notified in a timely manner, as required by facility policy and professional standards. Nursing notes and interviews indicated that staff, including RNs and LVNs, often failed to document or communicate these incidents to the appropriate parties. In several instances, falls and new bruising were observed and assessed by nursing staff, but notifications to the RP and hospice agency were either delayed or not made at all. Medication changes ordered by the hospice physician in response to the resident's behavioral changes were also not communicated to the RP. Staff interviews revealed confusion regarding documentation and notification procedures, with some staff reporting that they were told by previous management not to document certain incidents if the resident was care planned for such events. The lack of notification was confirmed through interviews with the resident's RP and hospice representatives, who stated they were not informed of several falls, behavioral changes, or medication adjustments. The facility's own policies required prompt notification of the resident's physician, RP, and hospice agency in the event of accidents, incidents, injuries, or significant changes in condition. The failure to follow these policies resulted in the RP and hospice agency being unaware of important changes in the resident's status, as evidenced by the RP only learning of some incidents through hospice or after reviewing the resident's chart.