Failure to Notify Family of New Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident’s family of a significant change in condition when a new stage 3 pressure ulcer was identified. The resident was admitted with diagnoses including cancer with metastasis to the bone and a history of stroke, and an admission MDS showed a BIMS score of 13/15, indicating the resident was cognitively intact. On 10/28/25, a wound care note documented a newly identified stage 3 pressure ulcer on the left heel measuring 5.0 x 5.0 x 0.2 cm with 100% sanguineous drainage, and an order was entered for daily and PRN wound care with normal saline, Medi honey, ABD pad, and kerlix. There was no documentation in the EMR that any family member was informed of this newly identified wound. During an interview, the resident’s family member stated he was not notified of any wound. In a separate interview, the RN reported that the resident was considered “his own person” and had not specified who or whether he wanted family notified of the wound, noting that the resident had three emergency contacts and no designated resident representative. The RN also acknowledged there was no documentation in the EMR that the resident had been asked about family notification or that he declined such notification. The facility’s “Notification of Change in Condition” policy stated that for competent individuals, the facility must still contact the resident’s physician and notify the resident’s representative, if known, and that when a resident is mentally competent, a designated family member should be notified of significant changes in health status because the resident may not be able to notify them personally.
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