F0580

D

Failure to Notify Representatives of Significant Changes in Condition

Arverne, New York Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately notify residents’ representatives of significant changes in condition, including an accident with injury and a new skin opening, as required by facility policy and 10 NYCRR 415.3(f)(2)(ii)(c). For one resident with schizophrenia, anxiety, dementia, and severe cognitive impairment, an unwitnessed fall occurred in the evening, during which the resident was found sitting on the floor with a laceration to the left eyebrow that required hospitalization. The accident/incident report documented that family was not notified and indicated “No Next of Kin,” and a nursing progress note also stated there was no next of kin to notify. However, the resident’s face sheet contained next of kin contact information, and there was no documented evidence that staff attempted to call the designated representative.

For another resident with non-Alzheimer’s dementia, Parkinson’s disease, cerebrovascular disease, and severely impaired cognitive skills, nursing documentation showed a new skin opening on the left dorsal foot, with the MD notified and treatment ordered. A subsequent nursing note recorded that the nurse called the resident’s next of kin to provide an update and would re-attempt contact later, but there was no documentation that the representative was ever successfully notified of this change in condition. The RN Supervisor who wrote the note later stated they did not recall if they actually reached the sibling, and they were out sick for at least a month afterward. The DON reported that next of kin notification is done by nursing or social work, that the RN Supervisor did not leave a voicemail per facility policy, and that the need for follow-up notification was not communicated in the end-of-shift report, leaving no evidence that the representative was informed.