Failure to Promptly Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to promptly notify the responsible party of a significant change in condition for one resident with severe cognitive impairment and total dependence on staff for activities of daily living. According to facility policy, the resident, attending physician, and resident representative must be promptly notified of any change in status or condition, including the development of new wounds. The resident was admitted with dementia and was at risk for pressure injuries. On a weekly skin integrity review, the resident was found to have an unstageable deep tissue injury to the right hip, a stage two pressure ulcer to the left hip, and moisture-associated dermatitis to the sacrum. Treatment was initiated, and the wound care physician was involved as documented. However, the responsible party was not notified of the wounds until several days after their discovery. The initial wound evaluation and management summary confirmed the presence of the wounds, but the responsible party only became aware after the physician called for a follow-up, at which point she realized she had not been previously informed. The Director of Nursing and Assistant Director of Nursing confirmed that the wounds were discovered and treatment started, but notification to the responsible party did not occur until several days later, contrary to facility policy.