Failure to Notify Provider of Pressure Ulcer Footwear Noncompliance and Significant Weight Loss
Penalty
Summary
The facility failed to notify the provider when a resident with a pressure ulcer did not wear the ordered orthotic shoes. The resident, who had diagnoses including cellulitis of the right lower limb, pain in the right foot, and non-Alzheimer's dementia, was assessed as having a Stage 3 pressure ulcer on the right foot. Orders were in place for custom orthotic footwear to promote wound healing, but observations revealed the resident was wearing regular work boots without orthotic inserts. Interviews with staff indicated confusion regarding whether the boots were custom orthotics, and there was no documentation that the provider was notified that the resident was not wearing the prescribed orthotic footwear. Additionally, the facility failed to notify the provider in a timely manner of significant weight loss in another resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson's disease and dementia. Weight records showed multiple instances of weight loss exceeding 5% in 30 days, but there was no documentation in the electronic health record or provider notes that the provider had been notified of these changes. Staff interviews revealed uncertainty about who was responsible for monitoring and reporting significant weight losses, and the dietician did not note the weight loss until a later date. The facility's policies required staff to report changes in condition, such as significant weight loss or changes in wound care, to the provider. However, in both cases, there was a lack of timely communication and documentation to the provider regarding these significant changes in the residents' conditions.