F0580

D

Failure to Timely Notify Provider of Resident’s Cognitive and Behavioral Decline

New Britain, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely notify a provider of a resident’s significant change in behavior and cognition, as required by its Notification of Changes policy. The resident had multiple diagnoses including vascular dementia without behavioral disturbances, alcohol and opioid dependence, generalized anxiety disorder, depressive episodes, and chronic pain. A quarterly MDS showed moderately impaired cognition with independence in mobility and no wandering behaviors. The resident’s care plan, dated 1/22/26, identified impaired cognitive function/dementia, poor impulse control, a history of altercations, psychoactive drug use, fall risk, alcohol abuse, and risk for disorientation, confusion, unsteady gait, and slurred speech, with interventions including monitoring and reporting changes in cognitive function and behavior, and every 15‑minute monitoring per a physician’s order dated 1/23/26.

Beginning on 1/23/26, nursing documentation reflected escalating behavioral and cognitive changes. A nurse’s note on 1/23/26 recorded the resident’s expressed desire to leave the facility and initiation of every 15‑minute checks. On 1/24/26, the resident was documented as confused, exit seeking, going into other residents’ rooms, and attempting to get to the elevator. On 1/29/26, notes again identified exit‑seeking behaviors, including the resident stating an intention to leave and not return and not wearing a Wanderguard. A psychiatric evaluation on 2/4/26 documented functional and cognitive decline that remained evident. However, review of the clinical record from 1/23/26 through 2/10/26 did not show that any provider had been notified of the increased confusion, wandering, or exit‑seeking behaviors during this period.

Further nursing notes throughout February continued to document increased confusion, wandering, searching for family members, and repeated attempts to access the elevator and exit, including entries on 2/12/26, 2/13/26, 2/17/26, 2/20/26, 2/22/26, and 2/23/26. A psychiatric APRN was first asked to see the resident on 2/11/26 after an incident in the dining room where the resident threw something in frustration, and again on 2/13/26 for exit‑seeking behavior, increased confusion, and agitation, at which time new PRN medication was ordered. On 2/20/26, the psychiatric APRN documented staff reports of continued confusion, sundowning, wandering, and exit‑seeking and ordered additional medication. On 2/25/26, nursing documentation showed that staff discovered the resident was not in the room or on the unit, initiated a search, and later learned the resident had exited the building and was returning. Interviews with the psychiatric APRN, Medical Director, and DON confirmed that the psychiatric provider and Medical Director were not notified of the resident’s initial change in cognition and behaviors when first identified, despite the facility policy requiring notification for significant changes in mental or psychosocial condition.