Failure to Notify Physicians and Obtain Timely Wound Care Orders Following Changes in Resident Condition
Penalty
Summary
The facility failed to promptly notify physicians and obtain appropriate wound care orders when residents experienced changes in condition, specifically related to pressure injuries. For three residents reviewed, there were significant lapses in communication and documentation. One resident developed an unstageable pressure injury to the right heel, but the wound care physician was not notified until two days after the injury was identified, and there was no documentation of physician notification or wound care orders on the day the wound was discovered. Additionally, after a surgical debridement, the facility did not contact the surgeon or wound care physician to obtain updated wound care orders. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but the facility did not obtain or implement wound care orders until several days after admission. Documentation showed that while the resident's physician was notified of the admission, there was no evidence that the wounds were reported or that wound care orders were requested at that time. For a third resident, the facility failed to monitor and report the status of a stage 4 pressure ulcer to the wound care physician, and there were gaps in the completion of required skin assessments. Interviews with staff revealed ongoing issues with accountability and follow-through regarding skin assessments and wound care. The facility did not have a dedicated treatment nurse, and regular nursing staff were responsible for these tasks, leading to inconsistent completion of assessments and treatments. Staff also reported confusion about when and how to notify physicians and document changes, and there was a lack of clear processes for ensuring timely physician notification and order implementation when residents' conditions changed.
Removal Plan
- Contact the facility wound care consulting provider to ensure no information had been relayed regarding the residents currently under care.
- Discuss Residents #11, #12, and #13 with the MDS Coordinator and the Assistant Director of Clinical Operations; ensure no new orders are needed.
- Contact the consulting wound care physician and inform of the resident being seen by the surgeon, debridement, and wound deterioration.
- Contact the resident representative and inform of the debridement, deterioration of the wound, and ask which consulting wound physician is preferred.
- Contact the wound care consulting physician to inform of the most recent measurements and wound condition for Resident #12.
- Compare wound measurements and condition for Resident #13 to previous observations and notify the wound care consulting physician.
- Notify the resident representative for Resident #13.
- Compare all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- Re-educate all nurses present regarding when to report skin issues to the provider vs. the wound care consulting physician, how to document physician communication regarding wound care, and how to contact the wound care consulting physician.
- Continue in-service until all nurses have been in-serviced and provide re-education prior to beginning their next scheduled shift.
- Review the 24-hour report to ensure a progress note is written when the wound care physician visits each resident and when the wound care physician is contacted to update with changes in wound condition.
- Provide education to all nurses regarding the completion of the Skin Issues evaluation when a new wound is discovered or when a resident is admitted with a wound, to notify the Director of Nurses and Facility Administrator, to notify the attending physician and/or the consulting wound care physician to obtain treatment orders and begin treatment orders immediately upon receipt, to make a notation on the 24-hour report of the new wound and to inform the Certified Nurse Aides of the residents wound and any changes needed for the residents plan of care.
- In-service nurses regarding admitting a resident with wounds, informing the physician of wound(s) discovered during the initial assessment, obtaining orders for treatment, ensuring orders for treatment are initiated immediately (not when electronic health record defaults to the next day), and inquiring about existing wound when receiving report from the discharging facility.
- Re-educate nurses regarding notification of the physician when there is a change in condition of a wound and remind to document all physician interaction in the electronic health record.
- Replace the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management to ensure treatment and services are provided to prevent and heal pressure ulcers.
- Hold a daily stand-down meeting by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.
- Conduct an impromptu QAPI meeting with the Facility Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations and Assistant Director of Clinical Operations.
- Ensure all residents have a current skin assessment completed and documented in the electronic health record and all residents with wounds are evaluated to ensure all appropriate interventions are in place and the attending physician and consulting wound care physician have been notified.