Failure to Notify Physician and Resident Representative of New Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to notify both the physician and the resident representative after a newly identified non-blanchable area of redness was found on a resident's sacrum. The resident, who had a history of hemiplegia, insulin-dependent diabetes, and dementia, was at moderate risk for pressure ulcers and required moderate assistance with activities of daily living. The non-blanchable area was discovered by the prior DNS during an overnight shift while assisting with incontinent care, and interventions such as a specialty mattress, turn schedule, and barrier paste were planned. Despite these interventions, there was no documentation that the physician or resident representative was informed of the new skin issue, as required by facility policy. Additionally, there was no evidence that a physical or occupational therapy evaluation was requested or completed, nor that the specialty mattress was implemented. The clinical record also lacked follow-up assessments or documentation regarding the sacral area after the initial finding, and the resident was not added to the weekly wound round list for further evaluation by the wound physician. Interviews with facility staff confirmed that the appropriate notifications and follow-up assessments did not occur. The APRN and wound nurse were not informed of the new skin issue, and the wound nurse indicated that the resident should have been added to the wound rounds for further assessment. Facility policy required notification of significant changes in a resident's condition to both the physician and resident representative within 24 hours, but this was not documented or carried out in this case.