Failure to Notify Resident Representative of Incident and Injury
Penalty
Summary
The facility failed to notify a resident's representative of an incident and a newly identified skin tear. The resident in question was admitted with multiple diagnoses, including cognitive impairment, and was documented as confused, with communication deficits that made it difficult to conduct a mental status assessment. The care plan indicated significant cognitive deficits, and the admissions record listed a family member as the resident's representative and emergency contact. On the date of the incident, the resident became agitated and combative, resulting in a skin tear on the left lower leg during a transfer to a wheelchair. A dressing was applied, and a Physician's Assistant was notified. However, there was no documented evidence in the medical record that the resident's representative was notified of either the incident or the resulting skin tear. Interviews with facility staff, including the Resident Case Manager and the Administrator, confirmed the lack of documentation and acknowledged that the family should have been notified, especially given the resident's cognitive status. Facility policy required notification of the resident's representative in such situations, but this was not followed in this case.