F0580

D

Failure to Notify Provider and Representative of New Toe Wound

Towson, Maryland Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely and appropriate notification of a physician and resident representative regarding a change in a resident’s condition, specifically a new wound on the left great toe. A resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, epilepsy, and type 2 diabetes mellitus was admitted on a prior date and had an active order dated 8/1/25 to be appraised and observed every shift for changes in physical and mental condition, with instructions to notify the provider if changes were observed. On 2/10/26, an LPN identified a new wound on the resident’s left toe, and the Treatment Administration Record for that date showed that the every-shift appraisal order was marked as completed, but there was no documentation that the provider was notified of this new physical change.

Further record review showed a Weekly Skin Check dated 2/4/26 documenting that the resident’s skin was intact, and a subsequent Weekly Skin Check dated 2/11/26 documenting "No New Skin Alterations" while also describing a left great toe wound with specific wound care orders, indicating the wound was present but not identified as a new skin impairment. The DON confirmed that the first documentation of the left toe wound was on the 2/11/26 Weekly Skin Check and acknowledged that the nurse should have documented it as a new skin impairment. The DON also confirmed there was no documentation that the provider was notified on 2/10/26 when the wound was first observed, despite an existing order to notify the provider of observed physical changes, and that an antibiotic (Doxycycline Hyclate 100 mg) had been ordered for the left great toe wound without corresponding documentation of provider notification on the date the wound was initially identified.