Failure to Notify Resident Representative of New Skin Condition
Penalty
Summary
The facility failed to notify a resident's representative of a new skin condition, specifically a bruise on the neck, as required by policy. A resident with dementia, anxiety, anemia, and Type II diabetes mellitus, who required substantial to maximal assistance for bed mobility and was dependent for transfers, developed a bruise on the left side of the neck and right jawline. Certified Nursing Assistants observed and documented the change in their charting, and a nurse on the previous shift was also aware of the condition. However, there was no documentation in the electronic medical record regarding the bruise or any notification to the resident's representative. Further investigation revealed that the bruise was initially identified by an LPN and reported to an RN for follow-up, but no assessment was documented, and the representative was not informed. The facility's policy required notification of the resident's representative in the event of a significant change in condition, such as a new skin condition, and documentation of this notification in the electronic health record. Interviews with staff confirmed that the required notifications and documentation did not occur.