Failure to Notify Physician and Document Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition and to monitor skin changes for a resident who developed rashes on the head and above the forehead. Documentation showed that a licensed nurse noted the rashes but did not provide evidence of physician notification or ongoing monitoring. Additionally, the same resident reported a previous unwitnessed fall and a wound on the scalp, but there was no detailed assessment or documentation of the wound's appearance or size prior to the resident's transfer to the hospital. The medical record also lacked documentation of the fall incident itself. An interview with the Assistant Director of Nursing confirmed that changes in condition, such as falls, rashes, or wounds, should be reported to physicians and thoroughly documented, including detailed wound observations. The facility's policy requires prompt physician notification and comprehensive documentation of observations prior to contacting the provider. The lack of documentation and physician notification resulted in delayed care and incomplete medical records for the resident.