Failure to Notify Physician and Obtain Treatment Orders for Pressure Ulcer on Admission
Penalty
Summary
A deficiency was identified when a resident admitted with multiple diagnoses, including diabetes mellitus and end stage renal disease, was found to have a Stage 2 pressure ulcer in the intergluteal medial cleft during the admission skin check. The ulcer measured 5 cm x 4 cm, showed no signs of infection, and the resident denied pain. Despite facility policy requiring that the physician be notified of any wounds or pressure ulcers at the time of assessment and that treatment orders be obtained, there was no documented evidence that the physician was informed of the pressure ulcer or that any treatment orders were obtained upon admission. Interviews with nursing staff and the Director of Nursing confirmed that the standard protocol was not followed in this case. The responsible RN stated that they did not receive a treatment order from the physician for the pressure injury, describing this as an oversight. The DON further clarified that while there are standing orders for different wound stages, the physician must be notified to determine the appropriate protocol. The lack of physician notification and absence of treatment orders for the pressure ulcer constituted a failure to provide necessary care and services consistent with professional standards of practice.