Failure to Promptly Notify Physician and Representative of Resident's Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician and the resident's representative of a significant change in condition involving a resident who developed skin tears and bleeding on both forearms. The resident, who had diagnoses including dementia, cerebrovascular accident, major depression, diabetes mellitus, and hypertension, was assessed as severely cognitively impaired and unable to make decisions. The care plan required monitoring for skin breakdown and reporting injuries to the physician. Despite this, the resident was found with dressings on both forearms, and neither the physician nor the resident's representative was informed in a timely manner. Interviews and record reviews revealed that the skin tears and bleeding occurred after the resident struck her arms on the bed siderails during personal care. The CNA who discovered and dressed the wounds did not report the incident to licensed nursing staff out of fear of suspension. The incident was only brought to the attention of the treatment nurse and subsequently the director of nursing after the resident's representative noticed the dressings and inquired about them. Documentation in the electronic medical record did not indicate how the injuries occurred or who applied the dressings, and there was no evidence of timely notification to the physician or the resident's representative, contrary to facility policy.