Failure to Notify Physician and Family of New Skin Wound
Penalty
Summary
The facility failed to provide timely notification to both the physician and the family for a resident who developed a newly documented open wound on the lower extremity. Clinical record review showed that the resident, who had severely impaired cognition and multiple diagnoses including coronary artery disease, congestive heart failure, Alzheimer's disease, and venous insufficiency, was assessed as not having any unhealed pressure ulcers or injuries prior to the incident. The care plan directed staff to observe and report any skin changes, and physician orders required weekly skin checks and prompt notification of new lesions or changes. Despite these directives, documentation revealed that a new open area was identified on the resident's left shin, but there was no evidence in the records that the physician or family were notified of this change. Interviews with staff confirmed that the expectation was to notify the physician, family, and appropriate facility leadership of newly identified wounds, and to document these notifications in the nurse progress notes. However, the responsible LPN could not recall if notifications were made, and the nurse progress notes did not reflect any such communication. The Director of Nursing also acknowledged that both the physician and family should have been contacted. Facility policy required notification of significant changes in a resident's condition, including changes in skin integrity, but this was not followed in this instance.