Failure to Notify Physician of Wound Deterioration
Penalty
Summary
The facility failed to notify a resident's physician of the deterioration of a non-pressure related skin wound. The resident, who was admitted with multiple diagnoses including a non-pressure chronic ulcer of the left heel, diabetes, and morbid obesity, had a care plan and treatment orders in place for a diabetic foot ulcer. Over the course of several weeks, wound care documentation and photographs showed that the resident's left heel ulcer increased in size, developed additional open areas, and exhibited worsening periwound erythema. Despite these changes, there was no documented notification to the resident's primary care physician or nurse practitioner regarding the wound's deterioration. Interviews with facility staff, including a nurse manager (LPN), a registered nurse, and the DON, confirmed that the wound had worsened and that the primary care provider should have been notified. The LPN acknowledged that the wound was no longer improving and appeared worse compared to previous evaluations, but could not provide documentation that the physician had been informed. The nurse practitioner covering for the resident's usual provider also confirmed there was no documentation of notification and stated that such notification would be expected when a wound increases in size or develops new open areas. Facility policy required that changes in a resident's condition, including wound deterioration, be promptly reported to the attending physician and documented. However, the review of records and staff interviews indicated that this notification did not occur, and there was no evidence of updated treatment orders or changes to the plan of care in response to the wound's decline.