Failure to Notify Physician of Change in Skin Condition
Penalty
Summary
The facility failed to ensure that a physician was notified of a change in a resident's skin condition. Weekly skin evaluations for the resident initially showed no issues, but a later assessment identified a rash and pressure ulcer. Despite this change, there was no documented evidence that the physician was informed. Interviews revealed that staff were aware of the skin impairment, with a GNA applying a non-prescribed cream and the nurse unaware of the issue, even though the nurse had documented the skin impairment in a prior assessment. The care plan indicated a history of periodic skin dermatitis, and the resident was on a daily topical treatment, but the new rash and pressure ulcer represented a change that was not communicated to the physician. Observations confirmed the presence of a large dry area and a small open area on the resident's skin. The GNA reported noticing the issue about a month prior and had been applying a cream not ordered for the condition. The nurse and unit manager were not aware of the current skin impairment until informed by the surveyor, and the Director of Nursing confirmed that the new rash should have been reported to the physician. No documentation was provided to show that the physician was notified of the change in the resident's condition.