Failure to Document and Communicate New Wound Resulting in Delayed Treatment
Penalty
Summary
A deficiency occurred when an LPN failed to document and communicate a newly observed wound on a resident's left foot. The wound was first identified by a CNA during bathing, who immediately notified the LPN. The LPN assessed the wound and recorded the measurements on her personal report sheet but did not enter the information into the resident's electronic medical record (EMR) or the designated wound/incision complex flowsheet. Additionally, the LPN did not notify the physician or ensure the wound was communicated in the shift-to-shift nursing report, as required by facility policy. The resident involved had a history of a right-sided middle cerebral artery stroke resulting in left-sided weakness and peripheral artery disease, placing her at increased risk for skin wounds. She required significant assistance with mobility, dressing, and bathing, and was dependent on staff for footwear management. A prior skin risk assessment had identified her as being at risk for skin wounds, and staff were instructed to observe and report any skin changes daily. Despite these risk factors and protocols, the new wound was not properly documented or communicated, resulting in a delay in physician notification and wound treatment. Interviews with other nursing staff revealed that the expected practice was to document new wounds in both the EMR and a paper communication sheet, notify the physician and family, and include the information in shift reports. The LPN involved was unaware of the requirement to document new wounds in the wound/incision complex flowsheet and believed she had communicated the information, though this was not confirmed by other staff. The lack of documentation and communication led to a delay in the evaluation and treatment of the resident's wound.