Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician when there was a significant change in the resident's condition, specifically the development of a Stage 2 pressure ulcer. The Wound Care Nurse identified the pressure ulcer on the resident's sacrum but did not document any notification to the physician, the resident, or the responsible party. The notifications section on the Skin and Wound Evaluation forms for the relevant dates was left blank, indicating that required notifications were not made or not documented. The Wound Care Nurse later stated she could not recall if she had notified the physician and admitted that such a change should have prompted physician notification and a referral to the NP Wound Nurse. The resident involved had multiple complex medical conditions, including sepsis, metastatic cancer, heart failure, severe malnutrition, dysphagia, muscle wasting, and incontinence, all of which increased the risk for skin breakdown. The resident was admitted with these diagnoses and was identified as being at risk for pressure ulcers. Despite these risk factors and the development of a Stage 2 pressure ulcer, there was no evidence in the medical record that the physician was consulted or that the change in condition was communicated as required by facility policy. Interviews with facility staff, including the Wound Care Nurse, DON, NP Wound Nurse, and other nursing staff, confirmed that the expectation was to notify the physician and other relevant parties when a resident developed a new pressure ulcer. However, the staff could not provide documentation or recall specific notifications being made in this case. The facility's own policy defined the development of a Stage 2 pressure injury as a clinical complication requiring notification of the physician, resident, and representative, but this protocol was not followed for this resident.