Failure to Immediately Notify Physician of Significant Change in Skin Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's health status, specifically regarding the development and progression of moisture-associated skin damage (MASD) in a resident with multiple complex medical conditions. The resident, an elderly female with a history of cerebral infarction, end-stage renal disease requiring dialysis, heart failure, diabetes, and other comorbidities, was at high risk for skin breakdown. Upon admission, she had no wounds but was identified as being at risk for pressure ulcers and MASD, with care plans and physician orders in place for prevention and treatment. Despite ongoing skin assessments and documentation of MASD and subsequent deterioration, there was a lack of timely notification and involvement of the wound care nurse practitioner (NP) as the resident's skin condition worsened. The wound care NP was not involved until the MASD had advanced to full thickness tissue erosion, despite facility policy requiring notification of the medical provider for new or worsening wounds. Interviews with staff, including nurses, the DON, and the wound care NP, revealed inconsistent understanding and execution of the process for escalating care and notifying the appropriate provider when the resident's skin condition failed to improve or deteriorated further. Documentation and interviews indicated that the wound care NP was not informed or involved until the condition had significantly worsened, and the previous NP was also not notified of the new or worsening MASD. The lack of immediate consultation and delayed escalation of care resulted in a delay in the treatment and services needed for the resident's skin condition, contrary to facility policy and care plan interventions that required prompt notification of the physician or wound care provider for significant changes in condition.