Failure to Notify Physician of New Pressure Sores
Penalty
Summary
The facility failed to notify physicians in a timely manner when two residents developed pressure sores. In the first case, a resident with multiple comorbidities, including cellulitis, lymphedema, and chronic kidney disease, developed a sacral pressure sore that was first identified by the Wound Care Nurse. The nurse did not immediately notify the physician or enter treatment orders into the electronic record, instead applying skin prep and later Santyl without physician consultation. The physician was not notified until several days later during routine rounds, at which point a more comprehensive treatment plan was initiated. In the second case, another resident with a history of diabetes, hypertension, and stroke returned from a hospital stay and was found to have an open area on the sacrum and a deep tissue injury to the right heel. Documentation was incomplete regarding the sacral wound, and there was no evidence that the physician was notified at the time of discovery. The Wound Care Nurse began treatment for the heel injury but did not notify the physician about the pressure sores. A one-time dressing order was obtained for the sacral wound, but there was no further documentation of physician notification or ongoing treatment orders until the resident was seen by the Wound Physician several days later, at which point a stage 4 pressure sore was identified. Interviews with nursing staff and the DON revealed that facility protocols required nurses to notify physicians and obtain orders for new pressure sores, but these protocols were not followed. The Wound Care Nurse and other staff members did not consistently communicate the presence of new wounds to the physician, and documentation was lacking. The Wound Physician confirmed that she was not made aware of the wounds until her scheduled visits, and the DON acknowledged that nurses should have contacted the physician and obtained appropriate orders when new pressure sores were identified.