Failure to Notify Physician of Wound Changes Resulting in Delayed Treatment
Penalty
Summary
Facility staff failed to notify a resident's physician of significant changes in a vascular wound, specifically increased redness, swelling, and pain in the resident's right second toe. The resident had a history of atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections, and had physician orders for daily foot checks with instructions to notify the physician of any changes. On the day the wound changes were observed, the LPN notified the facility wound nurse, but the physician was not contacted as required by policy and physician orders. The wound nurse acknowledged being informed of the changes but did not notify the physician, mistakenly planning to do so later and forgetting that the wound was under the care of a vascular wound physician. As a result, no treatment for potential infection was initiated until the resident's next scheduled wound clinic appointment four days later, at which point the wound was diagnosed as cellulitis and antibiotics were ordered. The delay in physician notification and treatment resulted in a delay in addressing the wound infection.