Failure to Notify Provider of Positive Wound Culture Result Delays Antibiotic Treatment
Penalty
Summary
A deficiency occurred when the facility failed to notify the Wound Provider of a positive wound culture and sensitivity laboratory result for a resident with vascular dementia, hemiparesis, and hemiplegia following a stroke. The resident was admitted with multiple wounds, including an unstageable left heel wound suspected to be of diabetic origin. The Wound Provider evaluated the wound and ordered a culture and sensitivity due to suspicion of infection. The laboratory report, completed and sent to the facility, indicated the presence of moderate proteus mirabilis and scant staphylococcus aureus. Despite the availability of the positive lab results, the Wound Provider was not informed of the findings when she visited the facility. Instead, she was incorrectly told by the Wound Nurse that the culture was negative, and she did not have access to the actual results. The Nurse Practitioner (NP) was also not notified of the laboratory results or the Wound Provider's treatment orders. The NP only became aware of the positive culture several days later, at which point antibiotics were ordered for the resident's infected heel wound. Interviews with facility staff, including the Wound Nurse, NP, and DON, revealed lapses in communication and delays in providing laboratory results to the appropriate providers. The DON acknowledged that the Wound Provider should have been shown the results during her visit, and the Medical Director confirmed that the delay resulted in the resident missing at least one day of antibiotic treatment. The Wound Nurse admitted to not having seen the results before reporting them as negative, contributing to the delay in appropriate care.