Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident’s Responsible Party (RP) of a change in condition when a new wound was identified. Record review showed that the attending physician had determined on 12/5/25 that Resident #96 was unable to comprehend and make medical treatment decisions, and the resident had an advance directive naming a healthcare power of attorney. On 12/10/25, a wound provider documented a new wound on the resident’s genitalia, and RN #34 also entered a change of condition note for this new wound. In the section of the note addressing notification of the resident representative, RN #34 documented that the resident, described as alert and oriented, refused to have family notified, stating that it was their genitalia and they did not want to tell them. During an interview, the DON confirmed that the RP should have been notified when the new skin condition was found and treatment was needed. These findings, based on record review of the complaint and facility-reported incident and interviews, showed that the facility did not ensure the RP was informed of the resident’s new wound and related treatment needs, despite the resident’s documented inability to make medical treatment decisions and the presence of a designated healthcare power of attorney.
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