Failure to Timely Notify Physician and POAHC of Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of a change in condition to both the physician and the activated Power of Attorney for Healthcare (POAHC) for a resident with severely impaired cognition. The resident, who had diagnoses including myasthenia gravis, hypertension, heart failure, and depression, sustained a skin tear of unknown origin. The injury was identified by a registered nurse during a skin assessment, and a physician update statement was prepared several hours later. However, the physician and POAHC were not notified of the injury until three days after it was discovered. Staff interviews revealed inconsistent practices and a lack of clear policy regarding when to notify physicians about skin tears. Nursing staff indicated that the decision to notify was left to their discretion, often based on the perceived severity of the injury. The facility's policy required immediate notification of the physician and resident representative for accidents or injuries with the potential for requiring physician intervention, but this was not followed in the case of the skin tear. The nursing home administrator confirmed that there was no specific policy for reporting skin tears and acknowledged that notifications should occur immediately, typically within 24 hours.