Failure to Notify Physician and Family of Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely notification to the physician and family regarding changes in a resident’s condition and treatment. Resident #1 had a history of atrial fibrillation, stroke, traumatic brain injury, and a narrowed heart valve, and had been receiving a diuretic during a recent hospitalization. The hospital discharge summary ordered the diuretic to continue for a defined period, but on admission the facility physician discontinued the diuretic, and a nurse’s note documented provider clarification to discontinue the PRN diuretic. The clinical record, however, lacked any documentation that the resident’s family or representative was notified of this medication discontinuation, despite staff interviews indicating that whoever processes a medication change is expected to notify the family and document the communication in the progress notes. Subsequently, the resident developed 3+ edema in the left arm from elbow to hand, as documented on the Summary of Daily Skilled Services. During a care conference, the occupational therapist reported edema in the resident’s arms that made ADLs more difficult, and the DON reviewed the resident’s weights and medications with the resident and her representatives. Despite these observations, the progress notes did not show that the provider was notified of the edema until a later date, and the note at that time did not include that the resident was having increased difficulty performing ADLs due to the edema. The resident’s care plan also lacked directives to notify the family or provider of anything other than abnormal labs to the MD. Later documentation showed that the resident told her daughter she wanted all her children to come see her and that she wanted to hear the voice of Jesus, indicating a change in behavior. The progress notes lacked any notification to the provider about this request or behavioral change. Multiple staff, including RNs and an LPN, stated in interviews that such comments and requests, if new for the resident, would constitute a change of condition requiring further assessment, provider notification, and documentation. The DON and other staff confirmed that facility policy required notifying the physician and family of changes in condition and documenting the time of call, person spoken to, reason for call, and response, but the resident’s record did not contain this required documentation for the medication discontinuation, the onset of edema, or the behavioral change.
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