Failure to Timely Notify Resident Representative of Injury
Penalty
Summary
The facility failed to notify a resident's representative of an injury of unknown source in a timely manner. On the day of the incident, a staff member observed the resident with a significant burn on his leg and directed him to return upstairs. The agency RN on duty documented the injury in the progress notes but did not contact the family. Interviews with staff confirmed that there was no immediate notification to the resident's family or representative regarding the injury, and review of the electronic health record showed no documentation of family notification at the time of the incident. The resident involved had multiple complex medical diagnoses, including type 2 diabetes mellitus, chronic kidney disease, and congestive heart failure, and was noted to have severely impaired cognitive skills. The wound was later evaluated as a full-thickness burn, and the family was not notified until 13 days after the injury, when consent was needed for a surgical debridement. Facility policy requires prompt notification of a resident's representative in the event of an injury, but this was not followed, as confirmed by staff interviews and record review.