F0710

G

Failure of Physician Supervision and Wound Management for a High-Risk Resident

Staten Island, New York Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s medical care was effectively supervised by a physician, in accordance with facility policy and regulatory requirements. The resident had multiple serious comorbidities, including end stage renal disease on hemodialysis, diabetes mellitus, and protein calorie malnutrition, and was assessed as having moderately impaired cognition and a moderate risk for pressure injury. Initially, the resident had no documented skin problems, but on 08/12/2025 an RN requested a wound care consultation without documenting an identified wound or notifying the attending physician. No wound assessment was documented until 08/14/2025, when the wound care nurse identified moisture associated dermatitis to the sacrum and bilateral buttocks and a physician ordered topical treatments for 30 days. Although a subsequent nursing note on 08/15/2025 documented skin openings to the bilateral buttocks and indicated that the wound nurse and physician were to evaluate, there was no documented evidence of wound progression, effectiveness of treatment, or clinical reassessment between 08/14/2025 and 11/29/2025, despite a later surgical note on 12/17/2025 describing a sacral wound with serosanguinous exudate and specific measurements.

After the resident was transferred to the hospital and later discharged back to the facility, the hospital discharge record documented eight wounds, including a Stage III sacral ulcer, unstageable and deep tissue injuries to both hips, deep tissue injuries to both heels, dry gangrene of the left toe, a necrotic right great toe, gangrene of all toes, and a left bunion with partial thickness skin loss. On readmission, the facility nurse documented pressure wounds to the sacrum, bilateral hips, gangrene to all toes, and bilateral heels, but the physician’s history and physical documented only moisture associated skin damage to the sacrum and did not identify the Stage III sacral ulcer or the other seven wounds listed in the hospital discharge summary. A physician order for collagenase was written without specifying the body site, and the treatment administration record showed the treatment as given on two days without identifying where it was applied. The wound care nurse’s assessment on 01/05/2026 documented only a right hip superficial abrasion, moisture associated dermatitis to the sacrum, and unremarkable lower extremities and heels, which did not correlate with the hospital discharge assessment or the nurse’s admission/readmission note.

Subsequent physician orders on 01/05/2026 addressed Medi-honey treatment for irritant contact dermatitis and Triad cream for a left hip abrasion, but there was no documented evidence of physician orders or treatment for four of the wounds: the right hip wound, left bunion partial thickness skin loss, and bilateral gangrenous toes. There was also no documented evidence of a podiatry consultation. The wound care physician assistant later documented assessments of the sacrum and left hip (identified as a Kennedy terminal ulcer) but did not assess the gangrenous toes or left bunion wound, stating they only examined areas directed by the wound care nurse. The readmitting physician stated they reviewed the hospital discharge record and saw moisture associated skin dermatitis but did not observe the hip wounds, attempted but did not document a refused lower extremity exam, and did not order podiatry because they did not assess the bandaged extremities. The attending physician for the unit reported never seeing the resident after readmission and was unaware of the multiple wounds and gangrenous toes, relying on the wound care team and unit nurses for communication. The medical director acknowledged reviewing the hospital discharge notes and seeing the list of wounds, stated that the readmitting physician should have ordered treatments for all wounds, and confirmed they did not physically examine the resident. Collectively, these documented omissions and incomplete assessments demonstrate that the resident’s medical care, particularly wound management, was not effectively supervised by a physician as required by facility policy and regulation.