Failure to Notify Physician and Resident Representative of Significant Change
Penalty
Summary
Facility staff failed to immediately notify the physician and the resident's representative of significant changes in a resident's condition on multiple occasions. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, experienced several changes in skin condition, including an area on the chest that was black and blue, skin tears on both wrists, blisters on both feet, and an open area on the left posterior shoulder. Documentation in the clinical record indicated that while some changes were noted and referred to medical staff, there was no evidence that the resident's representative was promptly notified as required by facility policy. Interviews with facility leadership confirmed the lack of documentation regarding immediate notification to the physician and resident's representative for the identified changes in condition. The resident's care plan included interventions to monitor and report changes in skin condition, and the facility's policy required prompt notification of significant changes. However, reviews of the clinical record and care plan revealed that these procedures were not consistently followed, resulting in a failure to communicate important health status changes to the appropriate parties.