Failure to Notify Representative of New Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative of a newly developed pressure ulcer. Record review showed that the resident, who was in a persistent vegetative state with diagnoses including acute respiratory failure, anoxic brain damage, and congestive heart failure, was readmitted to the facility. Initial skin checks and hospital discharge documents did not indicate a wound on the resident's left posterior ankle. However, a wound care provider later documented an unstageable, full-thickness pressure ulcer with necrosis on the left posterior ankle, noting it as present on admission per staff. Despite this new finding, there was no documentation in the nursing progress notes that the resident's representative was notified of the pressure injury. The Director of Nursing confirmed that the representative should have been notified when the wound was identified by the wound care provider. The facility's policy requires notification of the resident, physician, and family or legal representative when significant changes, such as the development of a pressure injury, occur. Interviews with staff and review of records confirmed the lack of required notification.