Failure to Notify Family of Significant Change and Hospice Denial
Penalty
Summary
The facility failed to notify a resident's representative of two significant events: the denial of hospice admission and the discovery of a large, painful bruise of unknown origin. Documentation shows that a medication aide first noticed the bruise on the resident's left side, radiating into the waist area and under the left breast, but it was not documented in the progress notes until several days later. The bruise increased in size and became painful, yet there was no record of a fall, no SBAR was completed, and the APRN was not asked to assess the bruise during a facility visit. Additionally, there was no skin assessment documented for the bruise prior to its entry in the progress notes, and the RN did not complete an incident report as required. Interviews confirmed that the resident's representative was not informed about the bruise or the denial of hospice admission. The representative, who visits the facility multiple times daily, only learned of the hospice denial after contacting hospice directly. Social Services and the DON both assumed that either hospice or another party would notify the family, but no such communication occurred. The lack of documentation and communication regarding these significant changes in the resident's condition and care status led to the identified deficiency.