F0580

E

Failure to Notify Providers of Critical Lab Result and New Skin Lesion

Corpus Christi, Texas Survey Completed on 02-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly notify physicians of significant clinical findings for two residents, contrary to professional standards, the residents’ care plans, and the facility’s own change in condition policy. For the first resident, an older female with multiple serious diagnoses including sepsis, severe sepsis without septic shock, stage 3 sacral pressure ulcer, unstageable coccyx wound, cognitive communication deficit, and other local skin infections, a critical laboratory result indicating Methicillin Resistant Staphylococcus aureus (MRSA) was reported on 02/16/2026 at 08:22 AM. Review of the resident’s progress notes for that date showed no documentation that the physician was notified of this critical MRSA result. The resident’s care plan required staff to observe, document, and report changes in skin integrity and to report improvements and declines to the physician, and the facility’s policy required physician notification for significant changes and discovery of injury or need to alter treatment.

For the second resident, an older female admitted with a cutaneous abscess of the abdominal wall and requiring wound care, the facility failed to notify the physician or NP when a new skin irregularity was identified on the right great toe. The resident, who had moderate cognitive impairment and was at risk for pressure ulcers, reported a black area on her right great toe to the NP on 02/20/2026 and stated she had informed the wound care nurse approximately two days earlier. The treatment nurse confirmed in interview that on 02/18/2026 she had been made aware of the toe lesion, assessed it as a blood blister, and then informed the charge nurse but did not notify the physician, NP, or on-call provider. She stated that notifying the physician was not within her scope and that it was the charge nurse’s responsibility, despite her role including performing skin assessments and wound care.

Additional interviews and record reviews further clarified the failures in notification. An LVN who worked on 02/16/2026 stated she was never made aware of the MRSA lab result for the first resident and that, during her shift, she reviewed the resident’s chart but did not see any critical lab results. The NP later discovered the critical MRSA result dated 02/16/2026 while reviewing labs on 02/18/2026 and reported that she had not been notified by the facility. The NP also reported that when she questioned the treatment nurse about the second resident’s toe lesion, the nurse acknowledged knowing about it since 02/18/2026 and had not sought orders. The facility’s change in condition policy required prompt notification of the attending physician or on-call physician when there was a significant change in condition or discovery of injury, but in both residents’ cases, the required physician notification did not occur as expected.