Failure to Notify Physician and Initiate Treatment Orders for Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the physician or provider regarding an unstageable pressure ulcer identified on a resident upon admission. The resident, who had multiple diagnoses including congestive heart failure, diabetes, and a history of pressure ulcers, was assessed with an unstageable pressure ulcer on the right hip during the admission nursing assessment. Despite documentation of the wound in daily skilled notes and skin assessments, there was no evidence of any treatment orders or dressing changes for the wound until several days later. Clinical record review showed that the pressure ulcer was present and documented, but no notification was made to the physician or provider, and no treatment orders were initiated until the wound nurse practitioner assessed the wound days after admission. Interviews with LPNs and the wound NP confirmed that standard practice required contacting the in-house or on-call provider for treatment orders when a pressure ulcer was identified, but this was not done. The director of nursing also confirmed that there were no documented treatments or dressing changes for the pressure ulcer until the wound NP's assessment. Facility policies required prompt notification of the physician or practitioner for changes in a resident's condition, including new or existing pressure ulcers, and for staff to report changes in skin integrity. Despite these policies, the required notifications and treatment orders were not obtained in a timely manner, resulting in a delay in care for the resident's pressure ulcer.