Failure to Notify Family of Resident's Significant Change in Condition After Hospitalization
Penalty
Summary
The facility failed to notify a resident's family member of significant changes in the resident's condition following her return from a seven-day hospital stay. Upon her return, the resident was found to have multiple new areas of skin breakdown, including bruising, open wounds, and excoriations, as well as a urinary tract infection requiring antibiotics. The resident also refused further skin assessments, antibiotic medication, and a blood test as ordered by her physician. These changes and refusals were documented in the resident's clinical record. Despite these significant developments, there was no documentation that the family member was informed of the resident's return to the facility, the new wounds, or the refusals of treatment. The family member confirmed during an interview that she was not notified of the resident's return, the assessment findings, or the refusals of care, and only became aware of the situation during a visit the following day. The Director of Nursing also confirmed that there was no record of such notifications and stated that staff assumed the family member was already aware due to her visits to the hospital. The facility's policy required staff to observe, record, and report any change in a resident's condition, including notifying the resident's responsible party. However, this policy was not followed in this instance, resulting in the family member being unaware of the resident's significant changes in condition and care refusals after her return from the hospital.