F0710

D

Failure of Physician Oversight and Timely Response to Worsening Venous Leg Ulcer

Jackson, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the failure of the Medical Director/attending physician to effectively oversee, supervise, and assess a resident’s medical care in relation to a worsening right lower leg venous stasis ulcer. The resident was admitted with diagnoses including a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, and had severe cognitive impairment with a responsible party designated for decision‑making. An order was in place for wound evaluation and treatment by an outside wound care company, and weekly skin assessments documented the wound’s status. On one weekly assessment, the wound nurse documented that the right lower leg venous ulcer measured approximately 15 cm x 5 cm x 0.4 cm post‑debridement, with 50% slough and 50% granulation tissue, significant drainage, no odor, no signs or symptoms of infection, and that the wound was showing improvement.

On a subsequent weekly assessment, the wound nurse documented that the same wound was worse, with the same measurements but now 100% slough/necrotic tissue and heavy drainage, though still noted as having no odor and no signs or symptoms of infection. During wound rounds on that later date, the wound doctor evaluated the resident’s right lower leg ulcer, determined that bedside wound care was not effective, and recommended hospital admission for operative debridement and possible above‑ and below‑knee amputation. The wound nurse later entered a progress note reflecting that the wound was worsening, had 100% slough/necrotic tissue, heavy drainage, and that the resident was in excruciating pain despite pre‑medication; this note was entered with a later date but described the earlier wound‑rounds encounter, and the nurse acknowledged she did not label it as a late entry to avoid it being flagged. The care plan for skin integrity was updated to include the wound doctor’s recommendation for hospital admission for operative debridement and possible leg amputation.

The Medical Director stated that the wound doctor informed him of serious concern about the resident’s non‑healing venous ulcer, significant vascular compromise, and the need for hospitalization and evaluation by a vascular surgeon. The Medical Director reported that he gave a verbal order to the wound nurse for a vascular surgery consult and expected it to be carried out by the following day, but he did not send the resident to the hospital at that time because he did not feel it was urgent and had not reviewed the wound doctor’s notes or the documented deterioration of the wound. The order for the vascular consult was not entered into the medical record until five days after the verbal order, and the DON confirmed that only two attempts were made to obtain consent from the responsible party for the vascular consult during that period. The Medical Director also acknowledged that he did not assess the resident’s right leg ulcer after the wound doctor’s recommendation and could not recall the last time he personally assessed the wound, stating he had not gone out of his way to observe it because the facility had a wound team.

Subsequently, the resident experienced a change in condition, with documentation by the wound nurse of low blood pressure (79/42), elevated respirations (30), slightly elevated temperature (99.6°F), non‑responsiveness compared to baseline, refusal of medications, refusal of breakfast, no fluid intake, facial grimacing with moaning, and refusal of pain medication. The resident was later sent to the hospital, where records showed presentation to the ED with confusion, increased heart rate, and low blood pressure due to septic shock related to cellulitis of the right lower extremity. Hospital findings included markedly elevated WBC, elevated lactic acid, CT evidence of a large soft tissue defect with fluid collection extending to the lateral ankle and forefoot muscles, and positive blood cultures for multiple bacteria. The resident was admitted to the ICU, later placed on comfort measures only, and died with causes listed as cardio‑pulmonary arrest, septic shock, and necrotizing fasciitis. Facility documents describing the Medical Director’s duties included coordinating medical care, participating in patient care review and infection control, being responsible for reviewing and evaluating patient care services, and making skin and high‑risk patient rounds, which contrasted with the Medical Director’s statements that he had not reviewed the wound documentation or assessed the wound after the wound doctor’s urgent recommendation.