Failure to Notify Physician of Pressure Ulcers on Admission
Penalty
Summary
The facility failed to notify the physician when pressure ulcers were identified on admission for one resident. Upon admission, the resident was found to have existing pressure ulcers on the right and left buttock and sacrum, as documented in the admission data collection assessment. The admitting nurse identified these wounds but did not notify the physician to obtain wound care orders at that time. Instead, the nurse reported the pressure ulcers to the oncoming nurse and left a note in the communication book for the Nurse Practitioner to see the resident during the next scheduled visit. No wound care treatments were initiated until several days after admission. Interviews with staff, including the admitting nurse, former DON, and Medical Director, confirmed that the physician was not notified as required when the pressure ulcers were identified. The Medical Director stated that he expected to be informed of such findings and that wound care treatments should have been implemented upon admission. The resident's medical history included muscle wasting, atrophy, and moderate protein-calorie malnutrition, which were relevant to the condition at the time of the deficiency.