Failure to Notify Physician and Document Treatment for New Skin Impairment
Penalty
Summary
A deficiency was identified when a resident with a history of cystitis, type 2 diabetes mellitus, and generalized muscle weakness was admitted with a right heel wound, but no other skin impairments. The resident's care plan included interventions such as weekly skin assessments, notification of changes to the physician, and documentation of any new skin breakdown. Despite these interventions, a new superficial blister with surrounding redness was observed on the resident's sacral area, but there was no evidence that the medical doctor was notified or that new treatment orders were obtained. The type of cream applied to the wound was not documented, and the nurse who provided the care could not recall the specific product used. Interviews with staff revealed that the certified nursing assistant would typically notify the nurse and wound care nurse if a new skin impairment was observed. The registered nurse who discovered the new wound applied a cream without obtaining a physician's order and did not notify the wound care nurse or document the specific treatment used. The wound care nurse was unaware of the new skin impairment, as she was on vacation at the time, and the director of nursing was covering her responsibilities. The director of nursing stated that staff should notify the provider and follow new orders when a change of condition is observed, but in this case, the wound care nurse was not informed, and the change was not properly documented or communicated. Review of facility policies confirmed that wound treatments should be administered per physician's order and documented in the clinical record, and that all changes in resident condition must be communicated to the physician and resident representative. The failure to notify the physician, obtain appropriate treatment orders, and document the care provided for the new skin impairment constituted a deficiency in pressure ulcer care and prevention.