Failure to Timely Administer Wound Care and Notify Physician of Wound Deterioration
Penalty
Summary
The facility failed to carry out a physician's order for the application of an antibiotic ointment to a resident's left heel ulcer, resulting in a nine-day delay before the treatment was initiated. The order, written by a podiatrist, was not entered into the resident's electronic medical record (EMR) until nine days after it was given, and the antibiotic ointment was not administered during this period. Nursing staff acknowledged that the omission occurred because the nurse who received the order did not enter it into the EMR, causing the treatment to be missed until it was later identified and corrected. Additionally, the facility did not promptly notify a physician when the resident's non-pressure wound showed signs of deterioration. Wound assessments documented an increase in wound size, the development of necrotic tissue, and the onset of drainage over several weeks. Despite these changes, there was no documentation that the physician or nurse practitioner was informed of the wound's worsening condition. The wound care physician was not contacted to assess the wound until more than a month after the deterioration began, and the resident's medical record did not show any refusal of services or documentation of timely notification to the appropriate medical providers. The resident involved had multiple complex medical conditions, including type 2 diabetes with a foot ulcer, chronic kidney disease with end-stage renal disease, and was receiving renal dialysis. The care plan required monitoring the wound and notifying the physician of any changes, such as increased size, drainage, or signs of infection. Facility policies also required prompt entry of physician orders into the EMR and timely notification of physicians regarding changes in wound status, but these procedures were not followed in this case.