Failure to Notify Physician of Wound Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician of a change in condition for a resident whose wound worsened. The resident, identified as being at risk for skin breakdown, had a care plan that required staff to check skin during daily care and notify the physician of abnormal findings. On observation, the resident was found with steri-strips on her right arm near the elbow, with green drainage visible on the wound, which is often a sign of infection. A Licensed Vocational Nurse (LVN) reported noticing green drainage from the resident's wound the previous day, cleaned the wound, applied triple antibiotic ointment, and left it uncovered, but did not notify the physician of this change. The LVN confirmed that the physician should have been notified. The Assistant Director of Nursing also stated that the physician should have been informed when green drainage was observed. Facility policy required nurses to notify the attending physician of significant changes in a resident's condition and to document such changes in the medical record.