Failure to Notify Physician and Implement Wound Care Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician of new wound care recommendations made by the Wound Nurse Practitioner for Moisture-Associated Skin Damage (MASD) to the resident's coccyx. The resident, who had diagnoses including unspecified dementia, seizures, syncope, hypertension, muscle weakness, and type 2 diabetes mellitus, was assessed by the Wound Nurse Practitioner, who documented specific treatment recommendations. These recommendations included cleaning the wound with normal saline, patting dry, and applying zinc and collagen sprinkles daily. However, there was no documentation that the physician was notified of these recommendations, no physician's order was obtained, and the recommended treatments were not implemented as evidenced by the absence of documentation in the Treatment Administration Record and progress notes. Interviews with nursing staff and the DON confirmed that the expected process was for nurses to notify the physician of the Wound Nurse Practitioner's recommendations and obtain an order to implement the new treatments. The nurse assigned to the resident was unaware of the Wound Nurse Practitioner's involvement and recommendations, and could not explain why the physician was not notified. The physician also stated she was not aware of the recommendations and would have implemented them if notified. The DON reiterated the expectation for physician notification and order acquisition but could not explain the lapse in communication and implementation.