Failure to Timely Notify Family and Provider of Deep Tissue Injury
Penalty
Summary
The facility failed to notify the resident's representative and medical provider in a timely manner following the discovery of a deep tissue injury (DTI) for a resident with a history of cerebral infarction and fragile skin. The resident was initially assessed as not being at risk for pressure ulcers, but developed a dark red area on the coccyx, which was first noted by an LPN. Documentation shows that the provider was notified and wound care orders were obtained after the wound opened, but there was no documentation of family notification until nearly two weeks later, despite the facility's policy requiring immediate notification of significant changes. Interviews and record reviews revealed that the family was not informed of the wound until they observed it themselves during a visit, and subsequent communication with the facility did not result in timely updates about the wound's progression. The resident's condition deteriorated, with decreased therapy progress, increased weakness, and decreased appetite, and the wound eventually became infected, requiring hospitalization. The DON confirmed that both the family and provider should have been notified at the initial discovery of the wound and again when it opened, but this did not occur as required. The facility's own policy mandates immediate notification of the resident, physician, and representative in the event of significant changes or injuries. However, documentation and interviews confirm that this protocol was not followed, resulting in a delay in communication regarding the resident's DTI and subsequent decline.