Failure to Notify Responsible Party and Physician of Change in Skin Condition
Penalty
Summary
The facility failed to immediately notify a resident's responsible party (RP) and physician of a significant change in the resident's physical condition. Specifically, a female resident with a history of major depression, schizophrenia, and other medical conditions developed Moisture Associated Skin Damage (MASD) on her buttocks, which later progressed to a non-pressure open wound with drainage. Documentation showed that the MASD was first identified during a weekly skin assessment, but there was no evidence that the RP or physician were notified at that time. The care plan was updated to reflect the skin impairment, but subsequent assessments continued to indicate that no new areas had been communicated to the physician or family. Interviews with facility staff confirmed that the RP was not notified of the resident's MASD until several weeks after the initial finding, when the DON contacted the RP regarding multiple skin issues. The LVN responsible for the initial assessment stated she believed the family had already been informed and admitted she did not recall notifying them. The DON and administrator both stated their expectation was for immediate notification of any change in condition, but acknowledged this did not occur in this case. The RP also confirmed she was not informed of the MASD until the later notification by the DON.