Failure to Notify POAHC of Resident Injuries After Multiple Falls
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's Power of Attorney for Healthcare (POAHC) of injuries resulting from multiple falls. The resident, who was severely cognitively impaired with a BIMS score of 0 and had diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and a history of falls, developed bruising on the legs and buttocks. Progress notes documented the presence of bruising and falls, but there was no indication that the POAHC was informed about the injuries, despite facility policy requiring notification of such changes in condition. Interviews and record reviews confirmed that the POAHC was not made aware of the bruising until the resident was sent to the emergency room, where the injuries were observed. The DON acknowledged that there was no documentation of notification to the POAHC regarding the bruising. The POAHC expressed distress at not being informed of the injuries, and the facility's own investigation and skin assessments confirmed the bruising was consistent with multiple falls and behaviors, yet notification was not provided as required.