Failure to Notify Responsible Party and Physician of Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident's responsible party and physician when there was a significant change in condition, specifically related to weight loss and the identification of a new wound. Interviews and record reviews revealed that a resident with multiple diagnoses, including Parkinsonism, impaired mobility, and a high risk for pressure ulcers, developed a new wound prior to discharge. The wound was identified by a registered nurse, who covered it with a dressing but did not notify the physician or nurse practitioner. The wound care nurse was informed about the new wound only shortly before the resident was discharged, and by the time the nurse attempted to assess the wound, the resident had already left the facility. Additionally, the facility did not notify the resident's family or responsible party about the new wound or the resident's weight loss, despite facility policy requiring immediate notification of significant changes in a resident's condition. The director of nursing confirmed that the family was not informed of these changes prior to discharge. The facility's policies on change of condition and weight monitoring require prompt communication with the physician and family when significant changes occur, but these procedures were not followed in this instance.