Failure to Notify Physician of Skin Alteration
Penalty
Summary
The facility failed to notify a physician of a significant skin alteration for one resident who was admitted with multiple bruises and an open area on the left great toe. Upon admission, the resident had intact cognition and was receiving treatment for a foot infection. Progress notes documented the development of new skin changes on the right foot, including discoloration, a large bump, and a fluid-filled blister. These changes were observed and measured by nursing staff over several days, with the area increasing in size and the skin becoming thin and transparent. Despite these documented changes, there was no evidence that the physician was notified of the new skin condition until several days after the initial observation. Interviews with facility staff confirmed that it was the expectation for nurses to notify the physician promptly when skin concerns arise. The physician only became aware of the wound during routine rounds, at which point medical intervention was initiated. Review of facility policy indicated that nurses are required to notify the physician or nurse practitioner immediately upon identifying a skin alteration, either by fax or phone, and to document the new order in the electronic health record. The delay in physician notification was not consistent with facility policy or staff expectations.