Failure to Notify Resident's Representative of Skin Condition
Penalty
Summary
The facility failed to notify a resident's representative regarding a significant change in the resident's skin condition. The resident, who was medically fragile and dependent on staff for care, developed a skin condition that was not communicated to the resident's mother. The mother discovered the condition during a visit and was informed by the care doctor that the resident had sores, which she had not been previously notified about. The facility's policy required prompt notification of changes in a resident's condition, but this was not adhered to in this case. The facility's documentation practices were inadequate, as there was no record of communication with the resident's representative about the skin condition. The nursing staff, including an LPN, failed to document the resident's skin condition in the progress notes or any other relevant records. The Director of Nursing (DON) acknowledged the lack of documentation and the failure to notify the resident's representative as required by the facility's policy. The report highlights that the facility did not maintain proper records or communication regarding the resident's skin condition. Despite the presence of policies for skin care management and notification of changes, these were not followed, leading to a deficiency in the facility's compliance with regulatory requirements. The lack of documentation and communication with the resident's representative was a significant oversight by the facility's staff.
Plan Of Correction
Internal and External communication is being focused upon, following our in-service for improved communication with patients, staff, providers, social services, families, parents and legal guardian/representatives. The staff will increase documentation, as evidenced by skin assessment, progress note and charting by exception. The DON will monitor for compliance with progress notes, assessments and appropriate notifications. This Plan of correction will be addressed in our QAPI Meeting scheduled for.