Failure to Notify POA of Resident's Injury and Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's Power of Attorney (POA) of a significant change in the resident's condition, specifically the discovery of new bruising and a subsequent shoulder dislocation. On the early morning of 9/5/25, staff discovered new bruising on the resident's left upper arm and shoulder. The hospice agency was notified, and an X-ray was ordered, which later revealed a dislocated shoulder. The resident was then sent to a local hospital for further evaluation. Throughout this period, there was no documentation or evidence that the resident's POA was informed by facility staff about the new injury, the X-ray, or the change in condition. Interviews with facility staff, including the RN, Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed that none of them notified the POA of the new bruising or the subsequent medical interventions. The facility's own policy requires immediate notification of the responsible party when a resident experiences an acute change in condition. Despite this, the POA only learned of the injury and the need for hospital evaluation from the hospice agency, not from the facility. Documentation showed that the POA was contacted about a room change, but not about the resident's injury or medical status.