Failure to Notify Family of Newly Identified Pressure Ulcers
Penalty
Summary
Facility staff failed to notify a resident's family representative of two pressure ulcers that were identified on the resident. The resident, who had a history of cerebral vascular disease and was assessed as having severely impaired cognitive abilities, was dependent on staff for most activities of daily living. On the morning of the incident, the resident experienced a fall, and the family was notified of this event. However, later that same day, staff identified an unstageable wound to the sacral area and a stage 2 wound to the buttocks, but there was no documentation or evidence that the family representative was informed of these new pressure ulcers at the time they were discovered. Interviews and record reviews confirmed that the wounds were first identified in the evening, and although hospice was notified, the resident's daughter was not informed until nearly two weeks later. Staff interviews revealed assumptions that the family had been notified, but a chart audit showed otherwise. The care plan for the resident specifically included the intervention to inform the resident and family of any new skin breakdowns, but this was not followed in this instance. The deficiency centers on the lack of timely communication to the family regarding significant changes in the resident's condition.