Failure to Notify Physician and Responsible Party of Worsened Wound
Penalty
Summary
The facility failed to immediately notify a resident's physician and responsible party when there was a significant change in the resident's condition, specifically a worsened wound to the sacrum. The resident, an elderly male admitted for respite care with a history of stroke, cerebrovascular disease, and right-sided hemiplegia, was receiving hospice care at the time of admission. Upon admission, a nonblanchable redness was noted on the coccyx. On a subsequent assessment, the wound was found to have deteriorated and opened up. Certified nursing assistants observed and reported the change to an LVN, who documented the issue and indicated that notifications would be made. However, interviews and record reviews revealed that neither the resident's physician nor the responsible party were notified of the worsened wound. The charge nurse acknowledged being informed of the new or worsened sore but did not make the required notifications. The responsible party only became aware of the wound after the resident returned home, and the nurse practitioner confirmed that the physician and nurse practitioner were not notified. Facility policy required notification of the physician and responsible party upon identification of new or worsened wounds, but this protocol was not followed in this instance.