F0552

D

Failure to Notify Responsible Party of Significant Change in Wound Status

Gardena, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition. The resident was admitted and later readmitted with diagnoses including diabetes mellitus, a Stage 4 sacral pressure ulcer, and COPD. A History and Physical dated 1/14/2026 documented that the resident was non-verbal and lacked capacity to make medical decisions, and a subsequent MDS dated 2/28/2026 showed severe cognitive impairment with dependence on staff for toileting, bathing, and personal hygiene. Upon readmission from a general acute care hospital, the admission Skin Reassessment dated 2/25/2026 showed the resident now had a Stage 4 sacral pressure ulcer, whereas the Treatment Nurse stated the ulcer had been a Stage 2 prior to transfer.

During interview, the Treatment Nurse stated that progression from a Stage 2 to a Stage 4 pressure ulcer was a significant change and that she notified the resident’s physician, nurse, and CNA, but was unable to notify the responsible party. She reported making one unsuccessful phone call to the responsible party and was unable to speak with them or leave a voicemail, and acknowledged she should have made another attempt. The DON stated that licensed nurses were responsible for notifying residents’ responsible parties when there was a significant change in condition and that such notification was important because it was the responsible party’s right to be informed and included in changes to the plan of care. The facility’s policy titled “Change in a Resident’s Condition or Status” indicated that, unless otherwise instructed by the resident, a nurse will notify the resident’s representative when there is a significant change in the resident’s physical, mental, or psychosocial status, which did not occur in this case.