Failure to Notify Physician and Obtain Orders for Wound Care Procedures
Penalty
Summary
Nursing staff failed to demonstrate competency in wound care management and in responding to changes in a resident's condition, as required by facility policy and state regulations. Specifically, a registered nurse and the wound care nurse did not notify the attending physician when a resident's sacral pressure injury worsened from Stage 2 to an unstageable wound, and later showed signs of infection. Documentation and interviews confirmed that the physician was not informed of these significant changes in the resident's condition, despite facility policy requiring such notification for significant changes. Additionally, the wound care nurse performed conservative sharp wound debridement (CSWD), an invasive procedure, on the resident's unstageable pressure injury without obtaining a physician's order. Both the wound care nurse and the director of nursing stated that they believed a physician's order was not necessary for this procedure, contrary to state regulations and facility policy, which require treatments to be administered only on the order of an authorized person. There was also no evidence that the physician was notified of the worsening wound or the procedure performed. The resident, who had been admitted with a sacrum fracture and was cognitively intact, developed a pressure injury during her stay that progressed in severity without appropriate physician notification or intervention. Within two days of leaving the facility, the resident was hospitalized for sepsis and osteomyelitis of the sacrum, conditions secondary to the infected pressure injury. These failures resulted in a delay in treatment and contributed to the worsening of the resident's wound.