Failure to Communicate and Document Physician Notification for Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the facility's own policies and procedures regarding wound care. The resident in question had multiple diagnoses, including type 2 diabetes mellitus, peripheral vascular disease, hypertension, heart failure, difficulty walking, and generalized muscle weakness. The resident was cognitively intact and had been assessed as having diabetic foot ulcers. Over the course of several weeks, wound care consultant (WCC) notes documented ongoing issues with the resident's left and right plantar heel ulcers, including changes in wound size, presence of odor, and recommendations for further interventions such as antibiotics and a bone scan. Despite repeated recommendations from the WCC to consult with the primary physician regarding possible antibiotics and a bone scan, there was no documentation in the medical record indicating that these recommendations were communicated to or acted upon by the primary physician. Progress notes from nursing staff indicated awareness of changes in the wound's condition, such as worsening appearance and odor, and stated that the Assistant Director of Nursing (ADON) and WCC would be notified. However, there was no follow-up documentation confirming that the physician was informed or that the recommended interventions were considered or implemented. Interviews with facility staff, including the ADON, LPN, and Director of Nursing (DON), revealed that the expected protocol was to notify the physician and document such communication in the electronic medical record when a wound worsened or when the WCC made recommendations. Upon review, the DON and LNHA were unable to find any incident reports, physician progress notes, or documentation of physician notification regarding the WCC's recommendations for the resident's wounds. This lack of documentation and follow-up constituted a failure to provide care in accordance with professional standards and the facility's policies.