Failure to Notify Provider and Representative of New Skin Impairment
Penalty
Summary
The facility failed to notify the provider and resident representative of a new skin impairment for a resident with multiple complex medical conditions, including atrial fibrillation, diabetes mellitus type II, congestive heart failure, chronic kidney disease stage three, liver cirrhosis, peripheral vascular disease, bilateral below the knee amputation, and altered mental status. The resident was admitted on 01/08/25 and discharged on 10/31/25. A quarterly Minimum Data Set assessment indicated the resident was cognitively intact and had no unhealed pressure ulcers at that time. On 10/24/25, a weekly wound and skin assessment documented a dark blanchable redness to the resident's bilateral buttocks, but no measurements or further wound characteristics were recorded. There were no new physician orders related to this skin impairment, and nursing progress notes did not show evidence that the nurse practitioner, wound nurse practitioner, or responsible party were notified of the new condition. Interviews with the wound NP and another NP confirmed they were not informed of the new skin impairment, despite one of them being present in the facility when the issue was identified. The Director of Nursing also verified that there was no evidence of notification to the NP or resident representative regarding the new skin impairment. Review of the facility's policy on changes in a resident's condition or status indicated that prompt notification of the resident, attending physician, and resident representative is required for changes in medical or mental condition, which was not followed in this instance.