Failure to Notify Physician and Family of New Skin Impairment
Penalty
Summary
The facility failed to notify both the physician and the resident's family of a new skin impairment in a resident with multiple complex medical conditions, including multiple sclerosis, diabetes mellitus, severe cognitive deficit, and dependence on staff for all activities of daily living. The resident was found to have an unstageable pressure ulcer on the right lateral elbow, which had deteriorated and increased in size due to a conjoined skin tear. The weekly skin and wound evaluation documented the presence and characteristics of the wound, including measurements and tissue description, but did not specify when the skin tear was discovered or how it occurred. Medical record review revealed no documentation indicating that the physician or the resident's family had been notified of the new skin tear. During an interview, a registered nurse confirmed the absence of documentation regarding the discovery, cause, or notification related to the skin tear. The facility's policy requires notification of the resident, practitioner, and resident representative when there is a change in status, such as the need to alter treatment or the occurrence of a new condition. This policy was not followed in this instance, resulting in a deficiency.