Failure to Notify Health Care Agent of Significant Change in Resident Condition
Penalty
Summary
Nursing staff failed to promptly notify the Health Care Agent (HCA) of a resident who had an invoked Health Care Proxy (HCP) when the resident experienced a significant change in condition, specifically the development of deep tissue injuries (DTIs) to both heels. The facility's policy requires prompt notification of the resident, attending physician, and resident's representative in the event of changes in medical or mental condition. The resident, who had moderate cognitive impairment and diagnoses including vascular dementia and diabetes, was found to have unstageable pressure injuries on both heels. Documentation in the nurse's progress note and incident report indicated that both the provider and family (HCA) were notified of the new skin developments. However, interviews revealed that the nurse had only notified the provider and not the HCA, mistakenly believing the Unit Manager had done so. The Unit Manager, upon review, did not recall notifying the HCA and stated that the nurse should not have documented notification unless it was personally completed. The DON assumed proper notification had occurred based on the documentation, but later confirmed that facility expectations require prompt notification and accurate documentation only after confirmation. The HCA ultimately learned of the injuries through a family member, not from facility staff.