Failure to Notify Physician and Responsible Party of Resident's Change in Skin Condition
Penalty
Summary
The facility failed to notify the physician and responsible party when a resident experienced a change in condition involving new skin redness between the skin folds of the lower abdomen. The resident, who had diagnoses including dementia and impaired mobility, was found by a CNA to have skin breakdown during a scheduled shower. The CNA reported the abnormal skin condition to the Treatment Nurse, who assessed the area and applied Zinc Oxide cream without obtaining a physician's order or documenting the condition in the resident's records. The Treatment Nurse did not notify the physician or the responsible party about the skin redness, assuming it was due to heat and would resolve in a few days. Further interviews revealed that another CNA also noticed discoloration and itchiness in the same area and reported it to the nursing staff, but there was still no documentation or notification to the physician or responsible party. The Director of Nursing confirmed that the facility's policy requires nurses to document changes in condition and notify both the physician and responsible party. The lack of timely communication and documentation regarding the resident's skin condition constituted a deficiency in care.