Failure to Notify Physician of New and Worsening Wounds
Penalty
Summary
The facility failed to notify the physician of new wounds for a resident with multiple complex medical conditions, including heart disease, diabetes, chronic kidney disease, and a left below-knee amputation. Upon admission, the resident was found to have fourteen wounds, including a blister on the right fourth toe that was not included in the physician's orders for wound care. Nursing staff observed maceration, drainage, and discoloration of the toes during dressing changes, but did not notify the physician about these wounds or their changes in appearance. Documentation shows that wound care orders were only in place for four of the fourteen wounds, and the remaining wounds, including those on the toes, were not addressed with new physician orders. Interviews with nursing staff revealed that they assumed the physician was already aware of the wounds or that wound care was being managed by others, leading to a lack of direct communication with the physician regarding the new or worsening wounds. The resident's primary care physician confirmed not being informed about the wounds since admission and did not assess the toes during a visit, as they were wrapped. Facility policy required staff to notify the physician and responsible party of new skin integrity issues, but this protocol was not followed in this case.