Failure to Notify Resident Representative of Change in Condition and New Breathing Treatment
Penalty
Summary
The facility failed to ensure a resident’s representative was informed of a change in condition and new treatment order. A cognitively impaired resident with diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and who was receiving oxygen therapy, was noted in a progress note on 12/21/25 at 6:22 a.m. to have slept well overnight, with staff noticing a cough and clear lung sounds. Later that day at 10:07 p.m., a progress note documented a physician’s order for albuterol sulfate nebulization twice daily for cough until 12/27/25, indicating a change in the resident’s condition and treatment. Record review showed no documentation that the resident’s representative was informed of this change in condition or the new breathing medication order. During interview, the LPN acknowledged she did not document that she spoke with the resident’s representative about the change in condition and new medication, and the DON stated the nurse should have documented that she spoke with the family regarding the change in condition and medication change.
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