Delayed Physician Notification and Treatment Orders for Pressure Ulcer
Penalty
Summary
A resident with diagnoses including dementia, seizures, and palliative care was observed to have a low air loss mattress and was receiving hospice care. The resident was noted to have severe cognitive impairment and required substantial to maximal assistance for bed mobility. On one occasion, nursing staff identified a four centimeter by three centimeter open pressure ulcer with exposed adipose tissue, drainage, and slough on the resident's right hip. The ulcer was cleansed and bandaged at that time. Despite the identification of the pressure ulcer, there was no documentation that the physician was notified or that a treatment order was obtained until 11 days after the initial discovery. The physician, power of attorney, and DON were eventually notified, and a treatment order was written and implemented. Facility policy required that the physician or wound specialist order pertinent wound treatments, but this was not followed in a timely manner for this resident.