Failure to Timely Notify Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's legal representative in a timely manner following a significant change in the resident's condition. The resident, who had severe cognitive impairment, lower extremity impairment on both sides, and was dependent on staff for transfers, toileting, and hygiene, was assessed with an open area on the right knee. Nurse notes documented the presence of a 0.5 cm open area with a white center, which progressed to a pinpoint hole with a large amount of pink-tinged drainage and bone protruding under the skin. Despite these significant findings, there was no documentation that the resident's representative was notified of the change in condition at the time it was identified. Further review showed that while the physician was notified and new orders were received for pain management and antibiotics, the resident's representative was not informed until later, after the wound had worsened and infection was suspected. Interviews with facility leadership confirmed that staff are expected to notify the resident's representative promptly after a change in condition, but in this case, notification was delayed without a valid reason. The deficiency centers on the lack of timely communication to the resident's representative regarding a significant change in the resident's health status.