Failure to Promptly Notify Physician of New Sacral Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a physician when there was a significant change in a resident’s skin condition, as required by its own skin program policy. The policy stated that when a resident develops a reddened area or wound, the licensed nurse must notify the resident, family, and physician of the reddened area or wound, with physician notification to occur during normal office hours unless a treatment order is needed. Resident #3 had a significant change in skin condition that was not promptly communicated to the physician, despite the facility’s policy and the resident’s risk factors. Resident #3 was admitted on 05/06/2024 and had a significant change MDS dated 01/22/2026 indicating the resident was always incontinent of bowel and bladder, dependent for bed mobility, and had no unhealed pressure ulcers at that time. On 02/14/2026, a CNA working day shift observed three dime-sized, fluid-filled blisters on the resident’s buttocks and reported this finding to the nurse. The LPN on duty acknowledged that it was reported to her that the resident had a skin condition on the buttocks, which she described as reddened and open, and she applied skin prep to the area. The LPN confirmed she did not notify the doctor or the resident’s responsible party and did not recall whether she documented her assessment. There was no documentation of a skin assessment for Resident #3 on 02/14/2026 in the medical record. On 02/18/2026, during a weekly body audit, a treatment nurse discovered a stage 3 pressure ulcer on the resident’s sacrum, measuring 8.1 cm in length, 9.2 cm in width, and 0.1 cm in depth, identified as an in-house acquired, new onset pressure ulcer with full-thickness skin loss. The nurse documented the wound, notified the nurse practitioner and responsible party, and obtained new treatment orders. The wound care nurse practitioner’s assessment on 02/19/2026 confirmed an acute stage 3 pressure injury with exposed adipose tissue and three open areas measured together as one wound. Interviews confirmed that the earlier skin changes reported on 02/14/2026 were not communicated to the physician at that time, resulting in a delay in physician notification until 02/18/2026.
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