F0580

E

Failure to Notify Provider of Non-Healing Leg Wound

Los Alamos, New Mexico Survey Completed on 12-19-2025

Penalty

Fine: $47,075

Summary

The deficiency involves the facility’s failure to notify the provider in a timely manner of changes in a resident’s skin condition, specifically a non-healing wound on the left lower leg. The resident was admitted to the facility and later discharged to the emergency room, with medical diagnoses including muscle wasting and atrophy at multiple sites, morbid obesity due to excess calories, a developmental disorder of scholastic skills, an adrenal gland disorder, hypopituitarism, and mild cognitive impairment. On one date, nursing documentation showed the resident reported bumping the lower left leg on a door, resulting in a skin tear measuring 3.2 cm by 2.6 cm; the RN cleaned the area with normal saline, applied steri-strips, and covered it with an Optifoam adhesive dressing. Subsequent nursing notes documented dressing changes and surrounding skin redness but did not document provider notification regarding wound progress.

The care plan initiated for the resident on a specified date and revised later identified a non-healing skin tear with a goal for the wound to be healed by a target date, and interventions focused on nutrition, hydration, and safe transfers. Weekly skin checks documented the initial identification of the left lower leg skin tear and later described an open lesion with 5+ pitting edema, but several weekly assessments lacked wound measurements. The wound report similarly showed multiple gaps where no weekly skin assessment documentation was found. When documented, wound measurements indicated that the wound persisted and changed in size over time, but there were periods without recorded assessments.

Physician orders reflected several changes in wound care treatments over time, including cleansing with normal saline or wound cleanser and use of Optifoam, NAD, xeroform, Santyl, collagen, ABD pads, and Kerlix, with some orders discontinued and new ones started. However, there were no changes in treatment orders between two specific dates despite the wound not improving. In an interview, the DON stated that all changes in wound status should be immediately reported to the provider and confirmed that the resident’s leg wound was not improving, that there were no treatment changes during the identified period, and that the treatment nurse and provider had no communication about the wound in that timeframe. The NP stated that the resident would not allow her to look at the leg and that she relied on nursing staff to report skin condition changes; she reported she was not informed that the wound was not improving.