Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when the facility failed to notify an attending physician of a documented change in a resident's condition. Specifically, a licensed practical nurse (LPN) observed that a resident was more confused and agitated, and reported this change in behavior, including the resident throwing a dinner tray, to the resident's representative. However, there was no evidence that the LPN completed a change in condition assessment or notified the resident's attending provider of these behavioral changes. The Director of Nursing (DON) confirmed that such a change in behavior should have triggered both an assessment and provider notification, but the records did not show that these actions were taken.