Failure to Notify Resident Representative of Wound Deterioration
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated representative of multiple documented changes in condition related to deteriorating lower extremity wounds. A resident admitted with acute osteomyelitis of the left ankle and foot had a history and physical dated October 7, 2025, indicating a change in cognitive function that affected her ability to make informed medical decisions, and her grandson was designated as the responsible party for medical decision-making. Review of the resident’s change of condition (COC) documentation from November through December 2025 showed that on November 21, 2025, staff noted deterioration of right and left heel diabetic wounds during wound rounds, with the primary care provider notified and the resident updated. On December 5, 2025, the right heel diabetic wound was again documented as deteriorating by a wound specialist, with updated treatment orders and a notation that the family or resident was notified, marked as “self.” On December 8, 2025, during wound care, dark brown/purple discoloration was observed on the right dorsum of the foot, the MD was notified, and documentation again indicated the family or resident was notified, marked as “self.” There was no documented evidence that the resident’s representative was notified of these changes in condition on November 21, December 5, and December 8, 2025. During an interview and concurrent record review, the LVN who completed the COC entries stated she recalled providing wound care and completing the COCs, and explained that the process for communicating a change in condition was to notify the resident, family or resident representative, and the primary care and wound care physicians. She acknowledged that on the three dates in question she notified only the resident and did not notify the resident’s representative, and stated she should have communicated the changes to the representative. In a separate interview and record review, the DON confirmed that the resident experienced changes in condition on those dates and that the resident’s representative should have been notified, consistent with the facility’s policy titled “Change in a Resident’s Condition or Status,” which requires the nurse to notify the resident’s representative and document information related to significant changes in the resident’s condition or status.
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