F0684

D

Failure to Obtain Physician Orders and Document Treatment for Admission Skin Wounds

Saint Louis, Missouri Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s physician and obtain treatment orders for multiple skin issues identified at admission, and to document these issues on the treatment administration record (TAR) for ongoing monitoring. The facility’s Skin Program Policy required that all residents be fully assessed on admission, that residents admitted with skin areas/pressure ulcers have treatment orders initiated upon admission, and that an individualized skin plan of care be developed. The resident was admitted on 12/19/25 with documented dependence in multiple ADLs, cognitive impairment, and incontinence, and the baseline care plan noted current skin integrity issues and referenced a skin assessment.

On the evening of admission, an LPN completed a skin check and documented several skin issues in the progress notes: an open lesion on the front right medial lower leg, an open lesion on the right lateral calf, a diabetic foot ulcer on the right great toe, and redness in the peri-anal area. A subsequent admission note the same night described redness to the groin and shearing areas on the front right shin, back of right ankle, and right big toe. However, there was no documentation that the resident’s physician was contacted for treatment orders for these identified skin issues, and the physician order sheet contained no corresponding treatment orders. The TAR for the period from 12/1/25 through 12/23/25 contained no entries to monitor or treat these specific skin issues.

In interviews, the admitting LPN stated that dressings were removed, the areas were cleaned with soap and water, and protective dressings and barrier cream were applied, but acknowledged forgetting to place the skin issues and any treatments on the TAR and not documenting attempts to contact the physician. The LPN reported only one undocumented attempt to contact the physician on the day of admission and no further attempts on the following days, despite working that weekend and changing dressings without documentation. Other LPNs and the wound care nurse indicated that they rely on the TAR to know which residents have skin issues requiring assessment or treatment, and that if a treatment is not on the TAR, they would not know to perform it. The DON and wound care nurse both stated that the admitting nurse should have contacted the physician for treatment orders, documented those orders on the POS and TAR, and documented multiple attempts to reach the physician. As of 12/23/25, when the resident died, the facility still had not contacted the physician regarding the identified skin issues, had not obtained treatment orders, and had not documented the skin issues on the TAR for ongoing monitoring and assessment.