Failure to Notify Physician of Resident's Rash
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including hemiplegia, polyneuropathy, morbid obesity, and chronic pain syndrome, developed a rash in the abdominal and breast folds. The facility's policy required that any changes in skin integrity be reported to the physician, and the resident's care plan included interventions to minimize skin breakdown, such as regular skin assessments and staff assistance with hygiene and repositioning. Despite these protocols, a skin assessment documented the presence of a rash, but there was no evidence that the physician was notified as required. The Skin Only Evaluation completed on the resident indicated a rash with moderate redness, but the section for provider notification was left blank, and no education was documented as provided. A late entry nurse's note, created several weeks after the initial finding, stated that the resident was cleaned and barrier cream was applied, but again, there was no indication that the physician was informed. Interviews with facility staff, including the Nurse Supervisor and DON, confirmed that the physician was not contacted regarding the rash, and staff were unable to provide a reason for this omission. The deficiency was further substantiated by the facility's own documentation and staff statements, which showed a lack of adherence to both the facility's skin care policy and professional standards of practice. The failure to notify the physician of the resident's rash meant that appropriate medical evaluation and treatment could not be initiated in a timely manner, as required by the resident's care plan and facility protocols.