Failure to Notify Physician of Unstageable Deep Tissue Injury
Penalty
Summary
The facility failed to notify a resident's primary care physician of an unstageable deep tissue injury (DTI) to the resident's left heel at the time of discovery. The resident, who had multiple diagnoses including COPD, pressure-induced deep tissue damage, and a history of traumatic brain injury, was found by a CNA to have a dark, painful mark on the left heel. The nurse observed an 8.0 cm unstageable pressure area with intact skin and notified management and the resident's power of attorney, but did not notify the physician. The weekly skin and wound evaluation confirmed the presence of an unstageable pressure ulcer with slough and/or eschar, but lacked a detailed wound description. Medical record review showed no evidence of treatment or intervention for the unstageable DTI at the time of discovery, nor documentation that the physician was informed. The resident's quarterly MDS assessment indicated risk for skin breakdown and the presence of an unstageable pressure ulcer not present on admission, with interventions such as pressure-reducing devices and skin care in place. The Director of Nursing later verified that the physician had not been notified when the wound was first identified. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in a resident's condition, which was not followed in this instance.