Failure to Notify Family of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family of a significant change in condition as required by facility policy and state regulations. Facility policy and nursing documentation dated 3/26/25 state that changes in a resident’s condition must be charted and that communication with family should be documented. The clinical record shows that a resident with multiple sclerosis, chronic pain, depression, and anxiety, who was alert, oriented, and able to understand and be understood, was admitted on an unspecified date and had an MDS dated 5/2/25. A nurse progress note dated 1/11/26 documented that the resident experienced choking and vomiting of food, was assessed, the physician was notified, and a chest X-ray was ordered. A subsequent nurse progress note dated 1/12/26 documented that the X-ray showed minimal right base atelectasis and that Augmentin 875/125 mg PO BID for 7 days was ordered for pneumonia. During an interview on 1/18/26, the resident stated that their son was not notified and that they had pneumonia for a week. Review of the progress notes did not show any documentation that the resident’s family was notified of this change in condition. In a later interview on 2/18/26, the Nursing Home Administrator confirmed that the facility failed to notify the family of the resident’s change in condition, resulting in noncompliance with 28 Pa. Code 201.18(b)(1), 201.29(d), 211.10(c)(d), and 211.12(d)(1)(2)(3)(5).
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