Failure to Inform Resident and Representative of Changes in Wound Care Provider
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed of, and allowed to participate in, treatment decisions, specifically regarding changes in wound care providers and treatment locations. Despite facility policies requiring residents and their representatives to be notified about the practitioners responsible for their care and to be given the opportunity to choose providers, the facility made a unilateral decision to discontinue sending residents to an external wound care clinic and instead transferred wound care to an in-house nurse practitioner. This change was made without notifying the affected resident or their power of attorney, even though the facility had previously communicated with the representative about other care matters. The administrator confirmed that no written or verbal notifications were provided to residents or their representatives about the change in provider or treatment location. The resident involved had multiple complex medical conditions, including osteomyelitis, peripheral vascular disease, diabetes, dementia, and multiple unhealed pressure ulcers. The resident was dependent on staff for most activities of daily living and had moderate cognitive impairment, requiring a representative to make medical decisions. The resident's representative was not informed of the discontinuation of care by the external wound care clinic, the change in medical director, or the revocation of attending physician privileges, and believed the resident was still receiving care at the clinic. The medical director also reported being unable to monitor the resident's wounds for several weeks due to the facility's decision, despite ongoing concerns about infection and the need for potential intravenous antibiotic therapy.