Failure to Notify POA of New Pressure Ulcer and Change in Condition
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) of a significant change in condition, specifically the development of a new stage 2 pressure ulcer on the sacrum. The resident, who was admitted with a diagnosis of failure to thrive and a history of pelvic fracture, was identified as high risk for pressure injuries and was dependent on staff for care and repositioning. The pressure ulcer was first identified by an APRN, but there was no documentation in the medical record that the POA was informed of the new wound or the need for new treatment, as required by facility policy. The resident's family was not notified until after the ulcer had deteriorated to an unstageable pressure injury with necrosis. Interviews confirmed that the POA was not made aware of the pressure injury or its treatment plan until much later, and the DON was also unaware of the wound at the time it was first identified. This deficiency is a repeat issue for the facility, having been cited in two previous recertification surveys. The lack of timely notification to the POA and family regarding the resident's change in condition and the progression of the pressure ulcer was substantiated through record review and staff and family interviews.