Failure to Notify Health Care Agent of Resident's Skin Condition Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Agent (HCA) of significant changes in the resident's skin condition, despite the HCA's authority being permanently invoked due to the resident's severe dementia. The resident, who had diagnoses including Type II Diabetes Mellitus and vascular dementia, developed a new area of Moisture Associated Skin Damage (MASD) on the buttocks and a fluid-filled blister on the left foot, both of which required new physician-ordered treatments. Documentation showed that the HCA was not informed of these changes, even though facility policy required notification of the resident's representative when new treatments or significant changes occurred. Interviews with nursing staff revealed that notification to the HCA was either not attempted, not completed, or not documented. One nurse stated that if she had notified the HCA, she would have documented it, but the relevant form was left blank. Another nurse attempted to call the HCA but did not retry when the call did not go through. The Director of Nursing confirmed that it was facility protocol to notify the HCA at the same time as the provider, but there was no evidence in the medical record that this occurred for either the new MASD or the foot blister.