Failure to Notify Physician and Representative of Wound Changes and Inadequate Wound Assessment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s representative of changes in a resident’s skin integrity and related treatment orders, and failure to comprehensively assess new and evolving wounds. The resident, who was paraplegic and chair/bedbound, had a care plan identifying shearing on both buttocks and high risk for skin breakdown, with interventions including barrier cream, dressings when areas were open and draining, and monitoring for signs of shearing and infection with reporting of abnormalities to the health care provider. Early faxed communications to the physician noted intermittent shearing on the buttocks and later increased skin breakdown and open sores associated with the resident’s refusal to get out of bed, but there was no evidence that the care plan was revised to address refusals or a repositioning program. Wound Data Collections from mid-December documented impaired skin integrity at the coccyx/sacrum but were not comprehensive, lacking wound measurements and type descriptions, and a physician note during this period did not mention shearing injury. Subsequent nursing orders directed cleansing of the buttocks and application of zinc oxide and ABD pads, and later documentation described shearing on both buttocks, darkened and reddened areas, and black and blue tissue, as well as a dried calloused area on the left lateral foot treated with iodine. However, between early and late December, records did not show that the physician was notified of new wounds or changes in treatment orders, and from late December through the end of the month there was no indication that the buttock wounds and left lateral heel were comprehensively assessed. The resident’s family member, listed as emergency contact, reported not being informed by the facility about the buttock wound and instead learning of its severity from a visitor who assisted with care. A certified wound NP reported that all prior wounds had been healed and that the wound clinic later received a referral for pressure ulcers on the right lateral foot and both buttocks. The DON stated that nurses should notify the physician of any change in condition, and the facility’s Notification of Change policy required immediate notification of the resident, physician, and resident representative when treatment needed to be significantly altered, but the records did not show such notifications occurred for these wound changes.
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