F0580

D

Failure to Notify Resident Representative of Change in Condition

Forsyth, Georgia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident representative of a change in condition for one resident. The resident was admitted with acute respiratory failure with hypoxia, thrombocytopenia, unspecified dementia with severely impaired cognitive skills for daily decision-making, and unspecified encephalopathy, and was dependent for ADLs and mobility. The resident had a PEG tube for dysphagia with orders for continuous Glucerna tube feeding and tube flushes, and the care plan included notifying the MD of any problems. Progress notes documented that the resident was restless, agitated, attempting to get out of bed, and pulling on the G-tube tubing. A subsequent note documented that the resident pulled out a Foley catheter with the bulb intact, resulting in a large amount of urine on the bed, and that staff were unable to obtain a urine specimen due to the resident’s uncooperative behavior.

Record review showed the resident was later discharged from the facility, and a complainant reported that the resident was still in the hospital, though no further information was provided. During interviews, the Director of Health Services stated there was no notification of change policy and confirmed that staff should notify the resident representative of falls, behavior changes, hospitalization, abuse and neglect, resident decline, changes in medication, and placement of devices such as a Foley catheter or IV. The administrator similarly stated that a change in condition, including Foley placement, should be reported to the resident representative and followed up with a progress note. Despite these expectations, the facility failed to provide notification of change to the resident’s representative for this resident, constituting the cited deficiency.