Failure to Timely Notify Physician and Family of New Wounds
Penalty
Summary
The facility failed to timely notify the physician and the responsible party regarding the development of new wounds in a resident. The resident, who had multiple medical diagnoses including aphasia, anemia, weakness, constipation, an unstageable sacral pressure ulcer, and vitamin D deficiency, was admitted with no identified skin impairments to the buttocks or coccyx. However, documentation later revealed the presence of an open area on the buttock and two new wounds, with specific measurements noted by nursing staff. Despite these findings, there was no documentation that the physician or family were notified of the new wounds at the time they were discovered. Additionally, nursing staff applied dressings to the wounds without a physician's order, and an official wound care order was not obtained until several days after the wounds were first identified. Staff interviews confirmed that neither the physician nor the family had been notified promptly, and that wound care orders were not in place until after the delay. Facility policy required physician notification when there is a need to alter a resident's treatment, such as a deterioration in health, but this protocol was not followed in this instance.