Failure to Notify Responsible Party of Wound Changes and New Medications
Penalty
Summary
The facility failed to notify a resident's responsible party regarding the development and deterioration of a pressure wound, as well as the initiation of new psychotropic medications. The resident, who was cognitively impaired and at risk for pressure wounds, was admitted with multiple skin issues, including dermatitis and a pressure ulcer. Documentation showed that the resident developed a dark, soft area on the right heel, which later opened and worsened, but there was no record of the responsible party being informed about these changes. Additionally, the resident was prescribed several new medications for depression, mood disorder, and agitation, including doxepin, Depakote Sprinkles, and hydroxyzine. Despite facility policy requiring notification and documentation of such changes to the responsible party, there was no evidence in the progress notes or physician documentation that the responsible party was informed about the new medication orders. Interviews with nursing staff and facility leadership confirmed that the expectation was for the responsible party to be notified of any new wounds, changes in wound condition, and new medication orders, with such communication documented in the resident's record. However, the review of records and staff statements indicated that these notifications did not occur as required, resulting in a deficiency related to failure to communicate significant changes in the resident's condition and treatment.