Failure to Notify Resident Representative of Treatment Refusals and Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative (RR) of changes in condition and refusals of treatment, despite a specific care plan and physician order requiring such notification. The RR had requested during a care plan meeting that staff call her whenever the resident refused medications, treatments, vitals, or procedures, and this request was incorporated into the care plan and entered as a physician order on the MAR to be acknowledged every shift from admission to discharge. Medical record review showed that the resident had ongoing, daily refusals of medications throughout the stay, and although the attending physician was notified, there was no documentation that the RR was informed of these refusals as required. Further review of the nursing progress notes showed that the resident experienced a fall in late summer, after which x‑rays and laboratory tests were ordered due to observed swelling; these tests were refused and never completed, and there was no documentation that the RR was notified. Later in the stay, the resident had another witnessed fall, and subsequent labs and imaging, including a urinalysis, were ordered and again refused in line with the resident’s documented history of refusals. The following day, nursing notes documented a change in condition with the resident being less responsive. The on‑call physician was notified and ordered monitoring and to respect the resident’s refusal of labs, with instructions to re‑offer if the condition changed or the resident became more agreeable. At no time, according to the record and interviews, was the RR notified or contacted to come in and assist, despite the existing care plan and orders. The resident was later transferred to the hospital for an extended stay with a diagnosis of sepsis, and the DON was unable to provide additional documentation showing that the RR had been notified of the refusals or changes in condition related to the falls and subsequent orders.
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