Failure to Notify Resident Representative of Change in Condition and New Orders
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition and new physician orders, as required by facility policy. The resident was admitted with multiple serious diagnoses, including anoxic brain damage, HIV, end-stage renal disease with dependence on hemodialysis, heart failure, tracheostomy, and sepsis, and was documented as Full Code with impaired cognition and unable to respond. On the Medicare 5-day MDS, the resident was noted to have a trach, pain regimen, feeding tube, pressure ulcer, continuous oxygen therapy, and to be receiving anticoagulant and anticonvulsant medications. On the cited date, progress notes documented that an LPN assessed the resident and found a bounding heart rate of 140, respirations of 36, blood pressure of 95/62, temperature of 98.9°F, oxygen saturation of 93% with trach in place, and use of accessory muscles. The physician was contacted and gave a verbal order for Lopressor 50 mg and to repeat vital signs in 30 minutes. After repeat vitals showed a heart rate of 112, respirations of 24, and blood pressure of 80/50, the physician gave new orders for midodrine 10 mg now and every six hours as needed, CBC, BMP, urinalysis with culture and sensitivity, and a chest radiograph. Medical record review and staff interview, including confirmation by the Director of Nursing, showed that no family or resident representative was notified of this change in condition or the new medical orders, contrary to the facility’s written policy requiring notification of the resident’s representative for changes in medical care, nursing treatments, and significant changes in mental or physical condition.
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