Failure to Notify Physician of New Skin Wound
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a new skin wound for a resident with multiple complex medical conditions, including congestive heart failure, cellulitis, MRSA infection, dementia, and muscle weakness. The resident, who was severely cognitively impaired and required maximum assistance, was at risk for pressure injuries and had a care plan in place for potential skin breakdown. Despite documentation of a skin tear on the resident's lower left leg, which was treated with steri strips, there was no notification to the physician at the time of the initial injury. Subsequent progress notes indicated ongoing issues with the wound, including the scab reopening and the presence of purulent drainage, but the physician was not notified until several days after the initial incident, at which point orders for wound culture were obtained. Interviews with facility staff confirmed that the expected protocol was to notify the physician and obtain orders when a new open area or skin tear was identified. The Director of Nursing acknowledged that the provider should have been notified when the open area first occurred. The lack of timely physician notification and failure to obtain treatment orders as required by the resident's care plan and facility policy led to the identified deficiency.