Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician and the resident's representative or family member after residents experienced a change in condition, specifically the development or worsening of pressure ulcers. This deficiency was identified through interviews and record reviews for three out of four sampled residents. The facility's policy requires licensed nurses to report changes in condition, incidents, or injuries to both the physician and the resident's representative or family member, and to document these notifications in the medical record. For one resident with severe cognitive impairment and multiple diagnoses, including acute kidney injury and altered mental status, skin assessments revealed the development of a coccyx pressure ulcer and a blister on the right heel. Despite these findings, there was no documentation of notification to the physician or family regarding these changes. Orders for wound care were entered without prior physician notification, and subsequent wound assessments continued to show no evidence of required notifications, even as the wounds progressed and developed drainage and odor. Another resident with moderate cognitive impairment and diagnoses such as hemiplegia, peripheral vascular disease, and diabetes developed multiple pressure injuries on the buttocks and heels. The medical record showed no documentation of physician or family notification for these wounds. A third resident, who was cognitively intact, also developed a coccyx pressure injury, with no evidence of notification to the physician or family. Staff interviews confirmed inconsistent practices regarding notification responsibilities, with some staff indicating that notifications were not routinely made for new or worsening wounds or changes in treatment orders.