Failure to Notify Resident’s Representative of New Orders and Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s chosen personal representative of new medical orders and changes in condition, despite the resident’s expressed preference and facility policy requirements. Resident B was admitted with multiple diagnoses, including congestive heart failure, chronic kidney disease stage 3, type 2 diabetes mellitus, and acute metabolic acidosis. An admission MDS assessment documented that the resident was cognitively intact, and a resident preferences evaluation indicated it was very important to the resident to have family or a close friend involved in their care. A Social Services note recorded that the resident wanted her granddaughter to be her emergency contact. However, multiple nursing progress notes over time documented that the resident exhibited chronic confusion. Record review showed that on numerous occasions the facility obtained new medical orders for Resident B without notifying the resident’s personal representative. On one date, new orders were obtained from the nurse practitioner for labs, melatonin, and acetaminophen at bedtime, with no documentation that the representative was notified. On another date, new orders were received for acetaminophen as needed for pain, metformin, lispro insulin, prednisone for COPD, and Robitussin DM for cough, again without notification of the representative. Subsequent physician and nursing notes documented an acute visit for dehydration related to elevated BUN, with orders for IV normal saline, followed by additional orders for IV fluids, Macrobid for a UTI, Keflex for cellulitis of the right leg, and hypodermoclysis for elevated BUN, all without documented notification of the personal representative. Further documentation showed additional new orders and a change in condition for Resident B without representative notification. Nursing notes indicated new orders for furosemide due to excessive fluid seeping from both lower extremities and an increase in Lantus insulin dosage, with no evidence that the personal representative was informed. When the resident complained of chest pain, a new order for nitroglycerin as needed was obtained and administered, and a subsequent order for a two-view chest X-ray was received; in both instances, there was no documentation that the personal representative was notified of the change in condition or the new orders. During interview, the resident’s emergency contact stated she had not been informed of her grandmother’s changes in condition or new orders and noted the resident had periods of confusion and would not understand the orders. The facility’s own Notification of Change policy required informing the resident, consulting the physician, and notifying the resident’s representative when treatment is altered, including new treatment, and specified that even competent residents’ representatives should be notified of significant health status changes, which did not occur in this case.
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