Failure to Promptly Notify Physician of New Coccyx Wound
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a resident’s change in condition, specifically the development of a new open skin area on the coccyx. The resident was admitted with multiple diagnoses including COPD, cardiac arrhythmia, OSA, CHF, lymphedema, RA, atherosclerotic heart disease, HTN, morbid obesity, major depressive disorder, and anxiety. A recent quarterly MDS showed a BIMS score of 13, indicating relatively intact cognition, and documented that the resident had unilateral upper extremity impairment and required maximal assistance for hygiene, toileting, rolling, and transferring. The most recent skin assessment dated 02/11/26 documented no skin impairments. On 02/18/26, during incontinence care, a CNA observed a large open area on the resident’s coccyx and notified an RN, who assessed the area and applied a cream. The CNA confirmed this was a new skin impairment. Review of the medical record the following day showed no documentation that the physician had been notified of this new wound. The RN who completed the 02/11/26 skin assessment confirmed there were no skin impairments at that time. The physician reported that when he last saw the resident on 02/11/26, the coccyx was reddened but not open, and he confirmed he was not notified of the new wound until 02/19/26, stating his expectation that new wounds be reported the same day they are discovered. Facility policy titled “Notification of Change” required prompt consultation with the resident’s physician when there was a significant change in condition, including deterioration in health, which was not followed in this instance.
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