Failure to Notify Physician of New Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to notify a medical provider of a new open wound for one resident. The resident was admitted on 12/10/2024 with pertinent diagnoses including diabetes mellitus. On 1/13/2026 at 4:55 PM, an EMR progress note documented that a new diabetic foot ulcer was identified on the left lateral mid-foot, acquired in-house, measured, and dressed. However, this documentation did not indicate that the physician was notified of the new wound or its characteristics, despite the facility’s policy requiring prompt physician consultation when there is a change requiring notification, including conditions with potential to require physician intervention and new treatments. During an interview on 2/9/2026, the Unit Manager acknowledged that the medical record lacked evidence that the medical provider had been notified of the new wound identified on 1/13/2026. The Unit Manager stated that mid-level providers review photographs, but also acknowledged that no medical providers had documented review of any photographs related to this wound. Review of the facility’s Notification of Changes policy and the job descriptions for RNs and LPNs showed expectations to report and record pertinent observations and to notify physicians under specified circumstances. As of survey exit on 2/10/2026, no additional information was provided to demonstrate that the physician had been notified of the new wound.
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