Failure to Inform Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to ensure that a resident's representative was adequately informed and involved in healthcare decisions, as required by policy. A resident with severe cognitive impairment and a history of skin cancer was receiving wound care for a cancerous lesion. Staff discovered maggots in the resident's wound during a dressing change, but the family was not notified of this significant change in the resident's condition. Documentation showed that while staff communicated with the family about moving the resident to a private room, there was no mention of the maggot infestation or discussion of treatment options, including possible hospitalization. Interviews with facility staff revealed that the LPN who discovered the maggots did not notify the family, and the DON also did not inform the family, assuming another nurse had done so. The physician assistant involved in the resident's care did not speak to the family directly, believing the DON had already communicated with them. As a result, the resident's representative was not given the opportunity to participate in or make informed decisions regarding the resident's care and treatment during a critical event.