Failure to Notify Wound Care Physician of Stage IV Pressure Wound on Admission
Penalty
Summary
The facility failed to notify the Wound Care Physician for evaluation and treatment of a Stage IV pressure wound on the left trochanter that was present upon admission for a resident with multiple diagnoses, including protein calorie malnutrition and anemia. Documentation showed that the resident was admitted with a Stage IV pressure wound, and physician orders were in place for wound care. Progress notes indicated the need for a wound care specialist consultation, but there was no evidence in the medical record that the Wound Care Physician was notified of the wound from admission through several weeks of the resident's stay. Interviews confirmed that the Wound Care Physician was not made aware of the resident's Stage IV wound until weeks after admission, despite the wound being documented and treated by nursing staff. The Wound Treatment Nurse, who was only present part-time, did not provide an explanation for the lack of notification, and the DON and Administrator were unaware of the failure until it was brought to their attention. The deficiency centers on the lack of timely notification to the Wound Care Physician for a serious wound present at admission.