Failure to Notify Resident Representative of COVID-19 Test Result
Penalty
Summary
The facility failed to notify a resident’s designated family member and POA of the resident’s COVID-19 test result after the family member specifically requested the test. The resident was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, generalized weakness, glaucoma with poor vision, and was documented as alert, oriented, and cognitively intact but requiring maximum assistance with ADLs. On the date of the change in condition, an LVN reported to an RN that the resident had vomited, and the RN notified the resident’s family member, who then requested that the resident be tested for COVID-19. The RN performed the COVID-19 test, which was negative, but there was no documentation in the resident’s medical record that the family member/POA was informed of the result. During interviews, the family member stated she was not informed of the test result, and both the LVN and RN confirmed there was no documentation of notification to the family member, despite acknowledging the importance of doing so, particularly because the test had been requested by the family member. The DON also stated that the RN should have documented that the family member was notified and that accurate and complete medical records and informing the resident and representative are rights. The facility’s Notification of Changes policy indicated that the SBAR form serves as documentation of communication with the physician and resident representative, and that progress notes should be used for other necessary information not on the form.
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