F0580

J

Failure to Notify Physician of Significant Change in Wound Status

Arlington, Texas Survey Completed on 01-10-2026

Penalty

Fine: $187,220

Summary

The deficiency involves the facility’s failure to immediately consult with a resident’s physician when there was a significant change in the resident’s condition, specifically a deterioration in wound status. The resident was an older female with a history of cancer, heart failure, and prior sepsis, cognitively moderately impaired, and at risk for pressure ulcers but initially documented as not having one. On 12/09/25, her care plan identified an unstageable wound to the buttock with interventions including monitoring for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. On 12/18/25, a skin check note documented a reopened wound to the sacrum and open areas to the left and right buttocks, and a wound care order was initiated to cleanse and dress the coccyx wound daily.

Over the following days, multiple staff observed and treated the wound, but there were gaps and inconsistencies in assessment, documentation, and physician notification. The Treatment Administration Record showed the ordered wound treatment was not completed on 12/19/25, and different nurses, including the wound care nurse (WCN) and LVNs, provided care from 12/20/25 through 12/25/25. CNA staff reported first seeing the open wound on 12/18/25 and notifying nursing, describing it initially as about the size of a dime, and later noticing it appeared more open on 12/21/25 and again notifying a nurse. LVN D, who performed wound care on 12/20/25–12/21/25, described the wound as about the size of a quarter, not very deep, and without drainage. The WCN stated that when she saw the wound on 12/22/25 it was about the size of a tangerine, curved in, without drainage or odor, and that she contacted the wound care nurse practitioner by phone but did not document this contact or notify the facility physician.

On 12/24/25, the wound care nurse practitioner conducted a first evaluation of the existing coccyx pressure ulcer, documenting it as an unstageable pressure ulcer/injury with malodor after cleansing, measuring 4.5 cm x 4.5 cm x 3.5 cm, with 40% granulation, 40% slough, and 20% eschar, exposed dermis and subcutaneous tissue, fragile and ecchymotic peri-wound with non-blanchable maroon discoloration, and moderate serosanguineous drainage. She ordered Dakin’s solution, iodoform packing, and superabsorbent dressings and requested a wound culture but was told the facility did not have supplies. The facility physician reported he was only notified about the wound on 12/18/25 and was not informed of any subsequent changes or suspected infection and did not assess the wound between 12/18/25 and 12/25/25. On 12/25/25, nursing documented the resident as stable when she left with her responsible party for a holiday outing. That same evening, the responsible party saw the wound at home, described having previously been told only that there was a “hot spot,” and took the resident to the hospital, where the emergency department physician documented an unstageable decubitus ulcer to the coccyx with foul odor and necrotic tissue. The facility’s failure centered on not immediately consulting the resident’s physician when the wound significantly changed and showed concerning characteristics, despite policy requiring physician notification for significant changes in condition, including changes in skin.

The surveyors determined that this failure to notify the physician of the significant change in wound status constituted a deficiency and identified it as Immediate Jeopardy on 01/08/26. Interviews with the WCN, DON, facility physician, CNAs, and other nursing staff confirmed that the physician was not kept informed of the wound’s progression or potential infection after the initial notification on 12/18/25, even as the wound increased in size, became unstageable, and developed malodor and necrotic tissue. The facility’s policy on change in condition required physician notification for significant changes in physical condition, including skin changes, but this was not followed in this case, leading to the cited deficiency.

Removal Plan

• Assess all residents with wounds; communicate the current condition of each wound with the resident's physician and the wound care nurse practitioner.
• Regional Nurse Consultant will provide education to the Director of Nursing, Treatment Nurse, and Assistant Director of Nursing on the Change in Condition policy as it relates to physician notification and documenting all wound characteristics, including measurements.
• Provide education to all nurses on the Change in Condition policy as it relates to physician notification, including changes in skin.
• Provide education to all nurses, including the treatment nurse, on documenting all wound characteristics, including measurements.
• Complete a competency test with nurses on physician notification related to changes in skin.
• Designate the Treatment Nurse to complete wound care; assign the Assistant Director of Nursing, Director of Nursing, or a designated nurse to complete wound care when the Treatment Nurse is unavailable; assign weekend wound care to the weekend supervisor or assigned charge nurse.
• Director of Nursing and/or designee will observe wounds to ensure documentation and proper notification are charted; immediately discuss discrepancies or concerns with the resident's physician and wound care practitioner and provide reeducation as needed.
• Director of Nursing and/or designee will review the wound care nurse practitioner's notes to ensure no additional concerns are noted.
• Conduct a QAPI meeting with the Medical Director to review the IJ template, identify root causes of the deficient practice, and implement the facility's plan to remove the immediacy.