Failure to Notify Physician of Worsening Pressure Injury
Penalty
Summary
The facility failed to notify a resident's physician of a change in the resident's pressure injury status. The resident was admitted with a stage 2 pressure injury to the coccyx/sacral area, which was initially small in size. Over time, wound assessments documented that the wound increased in size and drainage, but the treatment remained unchanged. The wound nurse was responsible for assessing the wound and noted its worsening condition, yet did not update the physician or nurse practitioner about the lack of improvement or the resident not being seen by the wound doctor. The nurse practitioner stated she was present in the facility and monitored the resident's medical condition, except for the wound, as she believed the wound doctor was following the case. However, she was not informed that the wound doctor was not involved. Facility policy required the attending physician to be notified within seven to fourteen days if there was a lack of response to treatment, but this notification did not occur. The resident's spouse also reported that the wound had worsened significantly by the time of hospital discharge.