Delayed Infectious Disease Consultation and Documentation Failure for Resident with Worsening Wound
Penalty
Summary
The facility failed to ensure the timely scheduling of an Infectious Disease (ID) consultation for a resident admitted with multiple comorbidities, including an infection following a fasciotomy and a urinary tract infection. Upon admission, the resident had a wound vac at the surgical site, and over the first two months, the sacral wound worsened, with increasing size and persistent infection despite ongoing IV antibiotics. Elevated C-reactive protein (CRP) levels were documented, indicating severe inflammation, and the need for an ID consult was repeatedly noted in both physician and nursing progress notes. The resident's responsible party was kept informed of the need for the consult, and the wound continued to be monitored and cultured as infection persisted. Despite multiple documented requests and orders for an ID consultation starting on 8/19, the consult was not completed until 28 days later. There was no documentation of the actual ID consultation report in the resident's electronic health record, and the Director of Nursing (DON) was unable to provide this documentation when requested. The delay in obtaining the required specialist consultation and the lack of documentation occurred prior to the resident's hospital transfer and subsequent admission with a diagnosis of sepsis.