Failure to Promptly Notify Family of Resident Injury
Penalty
Summary
The facility failed to promptly notify a resident's family or legal representative of a significant change in the resident's condition, as required by facility policy. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, diabetes with chronic kidney disease, and generalized anxiety disorder. Staff discovered discoloration, swelling, and pain in the resident's left lower extremity, with no record of a fall. The nurse on duty reported the injury to hospice and the Assistant Director of Nursing but did not notify the resident's Power of Attorney (POA) until several hours later. The facility's policy specifies that the resident's legal representative should be promptly informed of such changes, and documentation should be made in the nurse's notes. The delay in notification was confirmed through interviews and record review. The POA expressed dissatisfaction upon learning of the injury from hospice rather than directly from the facility. The nurse involved stated she was accustomed to a different protocol from another state, where hospice would notify the POA, but was informed by the Director of Nursing that this was not the correct procedure at this facility. The failure to promptly notify the resident's representative of the injury constituted a deficiency in following the facility's established policy for communication regarding changes in resident condition.