Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident with a history of dementia, chronic kidney disease, and Alzheimer's disease. The resident was admitted with significant cognitive impairment and communication deficits, requiring staff to communicate with family to determine the best approach for care. On a specific date, the resident developed a skin tear on her right ankle, and treatment orders were initiated and documented in the Medication Administration Record. However, there was no documentation that the resident's Power of Attorney (POA) was notified of the wound's deterioration or the new treatment orders, despite the facility's policy requiring such notification and documentation. Interviews with staff and the resident's family member revealed inconsistencies regarding when and if the POA was informed about the change in the resident's condition. The family member discovered the wound during a visit and was not previously informed about its presence or the treatment being provided. Staff members were unable to confirm the exact date of notification, and the Director of Nursing and Administrator acknowledged the lack of documentation regarding notification of the POA. The facility's policy mandates that changes in condition be reported and documented promptly, but this was not followed in this instance.