Failure to Notify Resident Representative of New Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a designated resident representative of a change in a resident’s condition, as required by facility policy and state regulation. The facility’s policy on Notification of Resident’s Change in Condition (dated 04/2020) states that when a change in condition is detected, the nurse must notify the physician, resident, or responsible party and document the date, time, name, method of notification, actions taken, and resident’s response in the medical record. Resident #1, admitted with multiple diagnoses including dementia with moderately impaired cognition, anemia, end stage renal disease on hemodialysis, diabetes mellitus, atrial fibrillation, coronary artery disease, heart failure, COPD, malnutrition, and respiratory failure, experienced a change in skin condition. On 08/12/2025, RN #3 requested a wound care consultation, but there was no documentation of an identified wound, no documentation that the attending physician was notified, and no wound assessment documented at that time. On 08/14/2025, RN #2 (wound care nurse) completed a wound assessment and documented moisture associated dermatitis to the sacrum and bilateral buttocks, described as moist, pink/red, with no odor, no drainage, and no pain, and treatment with Triad cream mixed with A&D ointment was ordered and administered every shift through the end of the month. The electronic medical record and treatment administration record contained no documentation that Resident #1’s designated representative was notified of this new moisture associated skin damage. In an interview, the resident’s representative stated they were not aware of the skin condition. RN #3 stated they did not notify the representative because they believed the wound care nurse was responsible for notifying families of skin problems and reported being not very involved with wounds due to the presence of a full-time wound nurse. RN #2 acknowledged usually notifying families of skin issues but stated they missed notifying this resident’s representative, and also stated that unit nurses could have notified the family. The DON stated the full-time wound nurse is responsible for notifying families of skin changes and that on weekends or holidays the unit nurse is responsible for such notifications.
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