Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
Facility staff failed to notify the attending physician of significant changes in condition for two residents. For one resident, who was cognitively intact and required extensive assistance with activities of daily living, staff identified a deep tissue injury on the right heel that progressed to an open wound with green/yellow discharge and foul odor. There was no documentation in the electronic health record that the physician was informed of this change in the wound's condition. The wound nurse confirmed that the physician should have been notified when the wound worsened. For another resident with moderate cognitive impairment and total dependence for care, staff identified a new stage 1 pressure ulcer on the coccyx. The electronic health record did not show that the physician was notified of this new wound. The wound nurse confirmed that the physician was not updated and acknowledged that the expectation is to contact the physician for new wounds. Facility policy requires immediate notification of the physician for significant changes in a resident's condition or the need to alter treatment.