Failure to Timely Obtain and Implement Dermatology Orders for Basal Cell Carcinoma
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement a dermatologist’s progress notes and treatment orders in a timely manner for a resident with a basal cell carcinoma (BCC) lesion on the left cheek. During observation, the resident was seen in the activity room with the facial wound open to air and long fingernails stained with a dried red substance. The wound care LPN stated that the resident had a state guardian, was seen weekly by a wound care NP, and that staff attempted to cover the lesion but the resident removed dressings and picked at the area. Dermatology notes from an appointment on 2/4/2026, with a post‑biopsy addendum dated 2/9/2026 identifying the lesion as BCC, documented that the lesion was exacerbated by scratching and that there was bloody residue under the resident’s left fingernails. The dermatologist’s plan included cutting and filing nails short, using an occlusive dressing or mittens at night to prevent manipulation, keeping the ulcer clean, and considering Silvadene applications. These dermatology notes, last updated on 2/9/2026, were not faxed to the facility until 2/23/2026 and were not uploaded into the EMR until 2/24/2026, approximately 20 days after the appointment. Facility wound progress notes dated 1/13, 1/29, and 2/12/2026 by the wound NP all indicated staff reported a dermatology appointment in March, and on 2/26/2026 the wound NP stated she had just seen the dermatologist’s recommendations that day and had not had a chance to review them, noting staff should have notified her earlier. The 2/12/2026 wound assessment documented the carcinoma lesion as 6 x 3.5 x 0.1 cm with 60% eschar and 40% devitalized tissue. The Treatment Administration Record showed an existing order from 9/13/2025 for daily betadine to the left cheek BCC, last signed on 2/21/2026, and the MAR showed a 2/12/2026 order for daily povidone‑iodine, last signed on 2/25/2026. The facility’s Wound Prevention and Healing policy stated that wound care services are to be provided under physician direction using a multidisciplinary approach, with the wound care team responsible for identifying problems, coordinating care, and providing case management, which was not followed in this instance.
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