Failure to Timely Notify Resident Representative of Wound Decline
Penalty
Summary
The facility failed to promptly notify a resident's representative of a significant decline in the resident's wound condition. The resident, who was cognitively impaired and required substantial assistance with daily activities, had a history of a stage two pressure ulcer on the sacrum/coccyx upon admission. Over the course of the stay, the wound deteriorated from a stage two to a stage four pressure area with necrotic tissue, as documented by the Assistant Director of Nursing (ADON). Although the physician was notified and new treatment orders were received, there was no documentation that the resident's representative was informed of the change in the wound's condition or the new orders at the time the decline was identified. The facility's policy required prompt notification of the resident, physician, and representative in the event of significant changes in condition, including wound deterioration. Despite this, the resident's family was not informed of the wound's decline until two days after the deterioration was documented, when they were present at the bedside. At that time, the family requested the resident be sent to the emergency room for wound evaluation. Interviews with facility staff, including the ADON, LPN, DON, and Administrator, confirmed that the family was not notified of the wound's decline or new treatment orders until the family was physically present at the facility. Staff interviews revealed a lack of clarity and follow-through regarding notification responsibilities. The ADON admitted to not notifying the family when the wound began to decline or when new orders were received. The LPN and DON both stated that family notification and documentation are required when there are changes in a resident's wound condition. The Administrator was unaware that the family had not been notified until after the fact and stated an expectation for timely notification of both the physician and family in such situations.