Failure to Initiate, Monitor, and Notify Physician of Resident Wounds
Penalty
Summary
The facility failed to initiate, monitor, and notify the physician regarding multiple wounds for a resident who was admitted with significant comorbidities and impaired skin integrity. Upon admission, the resident had numerous wounds, including a blister on the right 4th toe, abrasions, a stage 2 pressure ulcer, and a left below-knee amputation site. The initial wound assessment documented these wounds, but there was no corresponding physician order for wound care to the right 4th digit toe, and the care plan did not specify wound locations, treatments, or interventions for the identified wounds. Throughout the resident's stay, nursing staff provided wound care to the toes without physician orders, and documentation was inconsistent or incomplete. Several nurses and nursing assistants described the wounds as macerated, draining, and discolored, with some noting foul odor and difficulty separating the toes due to drainage. Despite these observations, staff did not notify the physician of the wounds' condition or deterioration, assuming the physician was already aware or that orders were not needed for all treatments. Progress notes indicated worsening wound conditions, including purulent drainage and discoloration, but lacked details on treatments applied or physician notification. The lack of timely physician notification and absence of specific wound care orders resulted in the resident's wounds worsening, ultimately leading to hospitalization and surgical intervention for wet gangrene and peripheral vascular disease. Interviews with staff and the resident's primary care physician confirmed that the physician was not informed about the wounds, and wound care orders were not entered into the medication administration record. Facility policy required notification of the provider and initiation of treatment orders for new or worsening wounds, but these steps were not followed for this resident.