Failure to Inform Resident Representative of Change in Skin Integrity
Penalty
Summary
The facility failed to document and inform a resident's representative about changes in the resident's skin integrity. A family member discovered bandages on the resident's right foot during a visit and reported not being informed of any wounds, which were not present at the previous visit. The resident, who had dementia, hypertension, diabetes, and moderate cognitive impairment, required assistance with activities of daily living. Medical records showed that an open sore was observed and treated, and a vascular wound was later identified on the right heel. Despite these developments, there was no documentation indicating that the resident's representative had been notified of the new wounds. The Director of Nursing confirmed the absence of such documentation. The facility's policy requires that residents and their representatives be fully informed of medical conditions and changes to the plan of care, but this was not followed in this instance.