Failure to Notify Physician of Wound Infection Signs
Penalty
Summary
The facility failed to notify a resident's physician of signs of a wound infection, as required by policy. A resident with diagnoses including atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections had an order for daily foot checks and physician notification of any changes. On one occasion, an LPN observed that the resident's right second toe was swollen, red, and painful to touch, and reported these changes to the facility wound nurse. However, the wound nurse did not notify the resident's physician or wound care physician about the change. The wound nurse acknowledged being informed of the wound changes but did not contact the physician, intending to do so later but ultimately forgetting. As a result, no treatment for a potential infection was initiated until the resident's next scheduled wound clinic appointment, at which time an antibiotic was ordered for cellulitis. The lack of timely physician notification delayed the initiation of appropriate treatment for the resident's wound infection.