Failure to Notify Legal Guardian of Significant Change and Injury
Penalty
Summary
The facility failed to notify the legal guardian of a resident with dementia, who was severely cognitively impaired, about significant events affecting the resident. The resident was admitted with a diagnosis of dementia and had a legal guardian listed as the primary contact for any changes. On a specified date, the resident was assaulted by a roommate, resulting in skin injuries to the left elbow and left pointer finger, and was subsequently seen in the emergency room. The resident was returned to the facility the same day and moved to a different room. Despite these significant events, the legal guardian was not informed of the altercation, the injuries, the emergency room visit, or the room change, as confirmed by both the legal guardian and facility staff during interviews and record review.