Failure to Notify Representative and Physician of Significant Change in Condition and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative and physician of significant changes in condition and treatment. The resident had multiple serious diagnoses, including intracerebral hemorrhage, unspecified dementia, tracheostomy status, and acute respiratory failure, and had a BIMS score of 00 indicating severe cognitive impairment. The resident’s care plan identified a risk for respiratory difficulties related to respiratory failure and included an intervention to notify the physician of any changes. Progress notes documented that the resident decannulated herself, respiratory therapy attempted three times to replace the tracheostomy, the stoma closed quickly, and the resident was then placed on 3 L/min nasal cannula with continued monitoring. The facility’s policy on change in condition required immediate notification of the resident, physician, and resident representative when there is a significant change in physical, mental, or psychosocial status. The resident’s family member, who was listed as emergency contact and power of attorney, reported that after the resident’s death they received a bill from a wound care company for treatment and removal of something from a wound, but the family had not been notified of any wounds or related treatment. The family member also stated they were not notified that the resident had been removing her tracheostomy tube and described the communication as horrible. The DON and ADON both stated they were unsure if the family or physician had been notified of any changes in the resident’s condition. One LPN reported not being familiar with the resident but stated she generally notifies families of changes, while another LPN stated the resident had a history of pulling at her tracheostomy tube and other devices and that after the resident extubated herself and was placed on oxygen and moved to another hallway, she (the LPN) always notified the family and physician of changes. However, there was no documentation or confirmation that the resident’s representative and physician were notified of the decannulation event or the wound care, leading to the cited failure to follow the facility’s notification policy.
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