Failure to Notify Physician and Representative of New Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and resident representative of a significant change in condition when a new deep tissue pressure injury (DTPI) was identified for one resident (R5). R5 had multiple diagnoses, including cerebral infarction with right middle cerebral artery involvement, dysphagia, reduced mobility, polycythemia vera, elevated white blood cell count, cerebral edema, type 2 diabetes mellitus, unspecified protein calorie malnutrition, and acute respiratory issues. A Brief Interview for Mental Status (BIMS) showed a score of 12, indicating moderate cognitive deficits. On 1/19/26, the wound care nurse (V7, LPN) documented that therapy staff notified her of a skin condition on the resident’s buttocks, and her assessment identified a DTPI to the sacral region. A wound summary completed the same day recorded a newly acquired DTPI to the sacrum measuring 1.20 cm by 0.40 cm with unknown depth. Despite this documented new wound, the physician order sheet contained no orders for treatment or management of the sacral wound, and the treatment administration record for January showed no wound treatment. During interview, V7 stated she had informed the physician about the sacral wound but, upon review of the progress notes with the surveyor, there was no documentation of physician or family notification and no physician orders implemented for the DTPI. V7 acknowledged she did not carry out physician orders and stated she “must have forgot,” and also described that facility practice requires notifying the resident’s family and physician and documenting the conversation when a new wound is acquired. The occupational therapist (V16) recalled observing a reddened area on the resident’s tailbone and immediately reporting it to V7, who said she would take care of it. The DON (V2) stated she did not recall the resident having a wound and explained that when a resident acquires a wound, nurses should be aware through communication tools, wound care orders, and progress notes, and that physicians and family should be notified with documentation of the change in condition. The facility’s written policy on Notification of Change in Condition requires immediate notification of the resident, physician, and resident representative when treatment must be significantly altered or a new form of treatment commenced, and requires documentation of notifications and new orders in the medical record, which did not occur in this case.
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