Failure to Notify Providers and Guardians of Resident Incidents and Changes in Condition
Penalty
Summary
The facility failed to notify appropriate parties, including providers and guardians, of significant changes in condition or incidents affecting three residents. In one case, a resident experienced a fall resulting in an injury above the right eye that required steri strips. The resident's guardian was not informed of the fall, as confirmed by both the guardian and facility staff, including an LPN and the Director of Nursing, who acknowledged the lack of notification. Another resident returned from the emergency room with scalp staples following a fall. The ER discharge instructions specified that the staples should be removed within 7 to 10 days. However, the facility's Registered Nurse Treatment Nurse (Wound Care Nurse) was not notified of the presence of the scalp staples until 24 days after the resident's return. Nursing progress notes indicated delays in obtaining physician orders for staple removal, and the wound care nurse, nurse practitioner, and DON all confirmed that timely notification did not occur. A third resident with a stage 4 pressure ulcer of the sacral region experienced a worsening of the wound, as documented in weekly wound progress forms and skin checks. Despite evidence of the wound increasing in size and the development of a new pressure ulcer, the facility's nurse practitioner and medical director were not notified of the decline until a significant delay had occurred. The nurse practitioner stated that earlier notification would have resulted in different wound care orders, and the medical director confirmed that immediate notification was expected when wounds worsen.