Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to provide timely notification to a resident's family member or representative after significant bruising was identified on the resident, which resulted in an ordered x-ray and temporary medication changes. According to the facility's policy, staff are required to promptly notify the resident, their physician, and their representative of any changes in the resident's condition, including injuries of unknown source, within 24 hours unless otherwise instructed by the resident. In this case, documentation and interviews confirmed that the resident's representative was not notified of the bruising, the x-ray order, or the medication hold, despite multiple opportunities and observations by staff. The resident involved had a history of heart failure, atrial fibrillation, tricuspid valve insufficiency, depression, and was taking an anticoagulant (Eliquis), which increased the risk of bruising. The resident was dependent on staff for most activities of daily living and was at risk for falls and impaired skin integrity. Staff observed extensive bruising on the resident's chest, torso, underarm, arms, and legs, and an x-ray was ordered due to pain, swelling, and bruising. Despite these significant changes in condition, there was no documentation that the resident's representative was notified, as required by facility policy. Interviews with various staff members, including CNAs, LPNs, the ADON, DON, RN, and the Administrator, revealed that while staff were aware of the bruising and discussed it in meetings, none could confirm that the resident's family had been notified. The resident also stated that their child is usually informed of changes in condition, but there was no evidence this occurred in this instance. Facility records, including progress notes and skin assessments, lacked documentation of any notification to the resident's representative regarding the bruising or related medical interventions.