Failure to Notify Practitioner of New Pressure Ulcers
Penalty
Summary
Facility staff failed to notify the medical practitioner of new pressure ulcers for two residents. For one resident, staff identified a skin issue on the left heel and obtained a one-time order to wash and cover the wound, but when a Nurse Practitioner assessed the area the following day and identified it as a stage 3 pressure ulcer, no treatment orders were obtained, and the practitioner was not notified to request further treatment. The resident was cognitively intact and required varying levels of assistance with daily activities. For another resident, staff noted an open area on the left side of the back, but there were no treatment orders for this wound or for a wound on the sacrum, as confirmed by a review of the treatment administration record. The DON confirmed that the practitioner was not notified of the wound until the day of the survey. The facility's policy requires prompt notification of the practitioner and resident representative when a change in condition necessitates new or altered treatment, which was not followed in these cases.