Failure to Notify Family/POA of New Wound
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's family or Power of Attorney (POA) of a new wound that developed on the resident's sacrum. The resident, who had multiple significant medical diagnoses including encephalopathy, malignant melanoma, end stage renal disease, epilepsy, chronic congestive heart failure, and dementia, was found to have skin breakdown with redness and open areas on the buttocks, as documented by an LPN in the progress notes. The wound was treated and documented in the medical record, but there was no evidence that the family or POA was informed of this new condition. The resident's family member and POA later stated that they were not notified of the wound and only became aware of it during a hospital visit. The LPN who discovered and documented the wound confirmed that the family was not notified and acknowledged that both the physician and family should have been informed and that such notifications should be documented. Review of the facility's policy confirmed the requirement for immediate notification of significant changes in a resident's condition to the family or representative, but no such documentation or notification was found in this case.