Failure to Notify Primary Emergency Contact of Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the correct emergency contact of a resident’s change in condition. The resident was admitted with severe unspecified dementia with behavioral disturbance and chronic pain, and had a BIMS score of 2/15, indicating severe cognitive impairment. An annual MDS indicated the resident did not have unhealed pressure ulcers at that time. Nursing progress notes documented that on 11/03/24 a charge nurse alerted the writer that the resident was noted with a blister to the right heel, and a message was left for emergency contact #2, with no documentation that emergency contact #1 was called. During a later phone interview, the first emergency contact (FM1) reported receiving a call from a nurse on 11/06/24 stating the resident had developed a wound to the buttocks and heel, and was told the right heel blister had been first noted on 11/03/24 and that the nurse had called emergency contact #2. FM1 questioned why they were not contacted first, as they were listed as the primary contact, and the nurse could not explain. The RN/Unit Manager and the DON both stated that facility practice and policy require staff to notify the first listed emergency contact of a significant change in condition, and if that person cannot be reached, to then call the second contact and document both calls. The DON confirmed that for this resident, emergency contact #2 was called and a message left, but emergency contact #1 should have been contacted instead, contrary to the facility’s policy on provider and responsible party notification of significant changes in condition.
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