Failure to Notify Family of Resident's Condition Change
Penalty
Summary
Woodhaven Health and Rehab Center was found to be non-compliant with federal and state regulations regarding the notification of changes in a resident's condition. Specifically, the facility failed to inform the family of a resident about a significant decline in the resident's health status. The resident, who had been admitted with diagnoses including peripheral vascular disease and type 2 diabetes mellitus with diabetic neuropathy, experienced a worsening of a pressure ulcer on the right lateral heel. The wound, initially assessed on October 28, 2024, showed a significant increase in size and severity by January 8, 2025, with the presence of eschar tissue and a mild wound odor, indicating a decline in the wound's status. Despite the facility's policy requiring notification of the responsible party or guardian in the event of a significant change in a resident's physical condition, there was no evidence in the clinical record that the resident's family was informed of this deterioration. This oversight was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the failure to notify the family in a timely manner for this resident.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under the state and federal laws. Director of Nursing educated on the policy and procedure for resident change in condition policy and the proper notification to responsible parties and physicians with a significant change in a residents physical condition by the Regional Director of Clinical Services. Nursing Home Administrator or designee is touching base with the family weekly to review any changes. The DON or designee will complete a 30 day look back to ensure proper notification was completed for residents with any changes with their wound assessments. Facility wound nurse will be educated on the policy and procedure for resident change in condition policy and the proper notification to responsible parties and physicians with a significant change in a resident's physical condition by the Director of Nursing. Licensed nursing staff will be educated on the policy and procedure for resident change in condition policy and the proper notification to responsible parties and physicians with a significant change in a resident's physical condition by the Director of Nursing or designee. To monitor and maintain ongoing compliance the DON or designee will audit 5 resident wound notes weekly x4 and monthly x2 to ensure proper notification was completed.