Failure to Notify Physician and Assess Rash on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and obtain treatment orders when a resident was readmitted with a rash on both lower extremities. The resident’s admission record showed an initial admission and a later readmission, with diagnoses including muscle wasting, atrophy, and lack of coordination. A History and Physical indicated the resident did not have the capacity to understand and make decisions, while a subsequent MDS documented that the resident was able to understand and be understood, and required varying levels of supervision and moderate assistance with ADLs and transfers. Progress notes from the readmission documented that the resident returned with a bilateral lower extremity rash. During an interview and concurrent record review, an LVN stated she admitted the resident on the readmission date, observed the bilateral lower extremity rash, but did not call the physician to notify him. She further stated she did not complete a Change of Condition assessment and no care plan was created related to the rash. The LVN acknowledged that the rash was not properly assessed and was not treated. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” indicated the facility should promptly notify the attending physician of changes in the resident’s medical condition or status, which was not followed in this case.
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