Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically the deterioration of pressure ulcers. The resident in question had a history of stroke with right-sided hemiplegia, severe cognitive impairment, and was at risk for skin integrity issues due to immobility and medication use. Documentation showed that the resident developed pressure ulcers on both buttocks, with one area worsening over time as noted in weekly skin assessments. The physician was notified of the changes via fax, but there was no documentation that the resident's representative was informed of the wound deterioration. A family member later reported to the facility that she had not been notified about the worsening of the resident's wounds. Staff interviews confirmed that wound assessments were conducted and physicians were notified, but the clinical record lacked evidence of timely notification to the resident's representative. The facility's policy required immediate notification of significant changes in a resident's status to the resident, their physician, and their representative, but this was not followed in this instance.