Failure to Notify Physician and Responsible Party of Pressure Ulcer Development and Progression
Penalty
Summary
The facility failed to notify the physician of pressure ulcers identified on admission and did not inform the responsible party when a stage 2 pressure ulcer worsened to an unstageable pressure ulcer for a resident. Upon admission, the resident was documented as having two stage 2 pressure ulcers on the bilateral buttocks, but there was no evidence that the physician was notified or consulted regarding treatment. The standing treatment order for stage 2 ulcers was not initiated until several days after admission, and the physician was not made aware of the wounds at that time. Further review revealed that the responsible party was not notified when the resident's right buttock ulcer progressed from stage 2 to an unstageable deep tissue injury, and later to a stage 4 full thickness pressure ulcer following debridement. Nursing staff and the wound care physician both failed to notify the responsible party, with documentation errors indicating notification had occurred when it had not. The responsible party only became aware of the wounds after the resident was discharged, prompting a grievance. Interviews with staff confirmed that the physician was not notified of the pressure ulcers on admission, and the responsible party was not informed of the progression of the wounds. The facility's own standing orders required physician and wound care physician notification for stage 2 wounds, but this protocol was not followed. The resident involved had severe cognitive impairment and was dependent on staff for care and communication regarding their medical condition.