Failure to Notify Physician and Obtain Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, staff did not notify the physician of the resident's weeping edema, redness, and blister on her right leg, nor did they obtain physician orders for wound care or the application of dressings prior to applying them. The resident, who had a history of edema, hypertension, and congestive heart failure, was observed with a nonstick dressing and gauze wrap on her right leg, which was swollen and red. The resident reported that nurses had applied these dressings due to a weeping blister and to prevent her sheets from getting wet. Interviews revealed that the physician was not aware of the resident's condition or the need for a dressing, and the Director of Nursing (DON) was also unaware that a dressing had been applied. The DON confirmed that staff had not notified the physician or obtained orders for the ace wrap or for the treatment of the swelling and weeping. Nursing staff admitted to applying dressings and wraps without physician notification or orders, despite facility policy requiring prompt notification of changes in a resident's condition, including skin conditions and swelling.