Failure to Notify Resident's POA of Wound Decline
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) representatives of a worsening pressure ulcer and the development of new wounds. The resident in question had multiple diagnoses, including paraplegia, dementia, and chronic conditions that increased the risk for skin breakdown. The care plans and clinical records indicated the resident was at high risk for pressure ulcers and had several wounds, including to the coccyx, left ankle, and left heel, with documented decline in wound status over time. Wound notes showed that the resident's husband was present and informed during some wound assessments, and the physician and spouse were notified of changes. However, there was no documentation that the resident's POA representatives, who were listed as the primary contacts for health and financial matters, were notified of the decline in the coccyx wound or the development of wounds on the left ankle and heel. The clinical record confirmed the absence of such notifications, despite the POAs being the designated representatives. During interviews, the Administrator acknowledged that the POA was not notified of the wound decline and that the facility did not have a policy regarding notification of a resident's representative about changes in condition. The lack of notification to the appropriate representatives constituted the deficiency identified in the report.