LOUISVILLE, KY – REGIS WOODS

Based on interview, record review, and review of the facility’s policies, it was determined the facility failed to have an effective system in place to ensure the physician and resident representative were notified of a resident’s change in condition for one (1) of eight (8) sampled residents, Resident #3. Interview and record review revealed on 02/18/19, the facility identified a new pressure wound on Resident #3’s coccyx and on 02/19/18; staff assessed the wound, which measured 1.0 centimeters (cm) by 1.8 cm by 0.9 cm. Interview with Resident #3’s family revealed the facility notified them of the initial assessment of the coccyx area and said it was the size of a quarter and superficial. The record revealed the facility followed their skin protocol for treatment and on 02/22/19; the wound measured 5.7 cm by 4.3 cm by 2.5 cm. Continued record review revealed the facility assessed and measured the wound on 02/28/19 and 03/06/19, with noted decline in the wound; however, did not notified the physician until 03/12/19, when the facility notified the physician the wound was odorous and possibly now infected. The physician summary notation, dated 03/12/19, revealed Resident #3 presented with a Stage 4 pressure ulcer with dead tissue in the wound. Interview with the physician revealed the facility did not notify her of the weekly wound measurements and the continual decline of the wound until 03/12/19. Interview with the Nurse Practitioner revealed the facility did not notify her of Resident #3’s wound condition and decline. In addition, interview with Resident #3’s family revealed the facility did not notify the family of the weekly decline until the facility and physician called to discuss palliative care on 03/15/19. On 03/18/19, the resident’s wound measured 28.9 cm by 7.9 cm by 5.1 cm and noted as unhealable.

Interview with the UM of the Nursing Facility (NF) 1 unit, on 04/04/19 at 4:15 PM, revealed she did not notify or request the physician to observe the condition of Resident #3’s coccyx wound. She stated the facility followed the skin protocol for Resident #3’s coccyx wound initially. The UM revealed it was not her priority to ensure the physician was aware of the change with Resident #3’s wound. The floor nurses were responsible to keep track of the changes and to notify the physician; however, she stated she completed the weekly wound assessment and measured Resident #3’s wound, not the floor nurses. She further stated Resident #3’s physician did not evaluate the wound until the middle of March, after the development of an odor, which was identified by the physician as an infection and a Stage 4 wound. The UM felt bad the physician was not notified earlier because she stated the resident was now on Hospice and would be systemically overwhelmed with the infection. Per interview, notification to the physician and family was basic nursing care and all staff completed annual training on when to notify a family and or the physician.