Failure to Notify Physician of Pressure Ulcer Progression
Penalty
Summary
The facility failed to notify the attending physician of a significant change in a resident's condition, specifically when a pressure ulcer progressed from Stage 3 to Stage 4. According to the facility's policy, the physician must be notified of any significant change in a resident's condition, including changes in pressure ulcer staging that require medical assessment and potential changes in the treatment plan. Review of the resident's health record showed that the pressure ulcer on the right gluteus was documented as Stage 3 on one date and then as Stage 4 with muscle exposure on a subsequent date. The wound consultant performed debridement, and the ulcer was reclassified as Stage 4. Despite these changes, there was no documentation that the physician was notified of the progression from Stage 3 to Stage 4. During an interview and concurrent record review, the DON confirmed that the physician should have been notified of the change in the pressure ulcer's stage and verified that the health record did not show such notification. This failure to notify the physician was identified for one of five sampled residents.