Delay in Physician Notification and Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to immediately consult with a resident's physician regarding a significant change in the resident's condition, specifically the deterioration of a pressure ulcer. The resident, who had a history of atrial fibrillation, chronic kidney disease stage 3, spinal stenosis, and sarcoidosis, was noted to have a worsening sacral ulcer with redness, odor, and drainage. The medical director (MD) assessed the wound and recommended immediate hospital transfer for debridement. However, facility staff delayed this action, waiting for orders from the nurse practitioner (NP), who wanted to assess the wound personally the following day. This resulted in a delay of more than 24 hours before the resident was sent to the hospital, despite the MD's recommendation for urgent care. Interviews with facility staff revealed that it was protocol to obtain orders from the NP even when the MD had already given a recommendation for hospital transfer. The MD was not informed that the NP disagreed with his recommendation, and the facility administrator expressed a preference for direct hospital or wound clinic admission rather than emergency room transfer. The facility's policy required staff to notify practitioners of significant changes in a resident's condition, but this was not followed in a timely manner, leading to a delay in necessary treatment for the resident's rapidly deteriorating pressure ulcer.