F0580

G

Failure to Notify Physician and Obtain Valid Orders for New Pressure Ulcer

Arkoma, Oklahoma Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately notify the physician of a new pressure ulcer and to obtain a valid, signed treatment order for one resident. The facility’s Notification of Changes policy required prompt consultation with the resident’s physician and notification of the resident’s representative when there was a change requiring alteration of treatment. An admission assessment dated 12/02/25 documented that the resident was severely impaired for daily decision making, dependent for rolling, at risk for developing pressure ulcers, and did not have a pressure ulcer at that time. A weekly nursing evaluation on 11/27/25 showed normal skin findings.

On 12/06/25, a nurse progress note documented that the resident developed a new, in-house acquired stage 2 pressure ulcer to the left gluteus, with exposed dermis and specific measurements. The note stated that the family, physician, and wound nurse were notified, and an unsigned physician order dated 12/07/25 directed application of Mesitran Soft Wound Gel and Medi-honey with dressing changes. The treatment administration record showed that wound care was provided as ordered. However, the ADON later stated that the wound care order obtained on 12/07/25 was not signed by a physician, did not recall who gave the order or how it was received, and acknowledged they did not notify the physician of the wound, believing the wound care company would sign the order and that writing orders was outside their scope of practice.

Additional documentation showed that the wound care company’s nurse practitioner first assessed the buttock pressure ulcer on 12/19/25, classifying it as unstageable and measuring it at different dimensions, and noted the wounds had been present for five days without being able to determine if they were improving or worsening. The wound care clinical schedule dated 12/12/25 did not list the resident to be seen by the wound care company, and the DON could not explain why the resident was not on the list. The wound care nurse practitioner did not recall any prior notification about the resident’s pressure ulcer before 12/19/25. The attending physician stated they did not treat wounds, did not write wound care orders, and did not write the 12/07/25 order, indicating that wound management was handled by the wound care company. These findings show that the facility did not follow its own policy to promptly notify and consult the physician when the resident experienced a significant change in condition requiring altered treatment.