Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident, resulting in the family not being informed of the development of a new wound and the initiation of antibiotic treatment. The resident, who had a history of cellulitis, peripheral vascular disease, and local skin infection, developed a new wound on the left foot and was started on antibiotics for a wound infection. Review of the electronic medical record showed no documentation that the family was notified of these changes. The wound care nurse, who also served as the unit manager, confirmed during an interview that there was no documentation of notification and attributed the omission to an oversight. Further interview with the resident's daughter revealed that she was not made aware of the new wound on the left foot, the initiation of antibiotics, or a previous wound on the buttocks. The daughter also stated she was not informed about a prior fall. Facility policy requires prompt notification of the resident's representative when there is a significant change in the resident's condition or when treatment is altered, but this was not followed in this case.