Failure to Notify Physician and Care Plan for Existing Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician, obtain physician orders, and implement a care plan for a resident admitted with a pressure-related skin issue. On admission in November 2025, the Nursing Admission/Readmission Evaluation documented that the resident had a pressure-related skin issue on the left buttock. Subsequent Daily Skilled Notes/Evaluations dated 11/30/25 and 12/7/25 indicated that the resident was receiving daily skilled care for pressure ulcer care and rehab services, and that the skin was not intact with a pressure ulcer on the left buttock. Despite this, there is no documentation in the report that a physician was notified, that specific physician orders were obtained for this existing pressure ulcer, or that an individualized care plan addressing this pressure ulcer was implemented upon admission as required by facility policy. On 1/5/26, a wound care nursing note documented a new skin issue on the left sacrum, identified as a Stage 3 pressure ulcer with full-thickness skin loss that was acquired in-house. During an interview on 1/6/25, the Wound Care Nurse stated that a CNA first brought concerns about a wound on the resident’s buttocks to his attention on 1/5/26, and that this was the first time he had heard of this wound. The facility’s Pressure Injury Prevention Management Program policy requires that, based on the resident evaluation process, an individualized comprehensive care plan be implemented by the interdisciplinary team, including a preventive care plan upon admission and a care plan for any actual pressure injury identified on admission/readmission. The Director of Nursing Services confirmed the above information during an interview, supporting the finding that the facility did not follow its policy to ensure appropriate physician notification, orders, and care planning for the resident’s pressure ulcer present on admission.
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