Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician and resident representative of a change in condition when the resident developed Moisture-Associated Skin Damage (MASD) to the coccyx. According to the facility's policy, prompt notification of the resident, physician, and representative is required for any change in the resident's medical or mental condition. Medical record review showed that the assessment documented the presence of MASD and included a plan of care and wound care orders, but did not indicate that the physician or resident representative had been notified of the change. Additionally, the assessment did not specify which physician provided the wound care order. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the physician and resident representative were not informed of the resident's change in condition. Staff also reported that treatment nurses sometimes entered wound care orders themselves without physician involvement. The DON verified that the facility's expectation is for licensed nurses to notify the physician for interventions and to inform the family or responsible party, but acknowledged that this did not occur in this instance.