Failure to Notify Physician of Wound Deterioration
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's wound status. A resident with a history of diabetes, multiple lower extremity amputations, and chronic wounds was admitted with several wounds, including a superficial wound on the right lower leg. Hospital discharge paperwork indicated a wet to dry dressing was ordered for bilateral shin wounds, but the facility's documentation and treatment orders did not reflect this change. Upon observation, the wound on the right lower leg had progressed from a superficial wound to one with 100% slough, but this change was not documented or communicated to the physician. Nursing staff providing care to the resident did not document the presence of slough or notify the physician of the wound's deterioration. The physician confirmed she was not made aware of the change until the wound was observed by the surveyor and facility staff. The facility's own wound care policy required documentation of wound assessment data and notification of changes, but these procedures were not followed, resulting in a failure to inform the physician of the resident's wound progression.