State Findings:
Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to notify the physician of a change in condition and need to alter treatment for one (1) of three (3) sampled residents (Resident #5).
The facility readmitted Resident #5 on 09/27/19 after a hospital stay. Staff interviews revealed the resident’s physician was notified on 09/27/19 of the scabbed areas to the resident’s lower extremities and right ankle. The physician had instructed staff to leave the scabbed areas open to air and to monitor them. However, review of the nurse’s notes from 09/28/19 thru 10/07/19 and staff interviews revealed no evidence of monitoring of the scabbed areas on Resident #5’s legs and ankle. Observation during a skin assessment on 10/07/19 with staff revealed a Stage 3 Pressure Ulcer (PU) on Resident #5’s right outer ankle that was not previously identified by nursing staff. The facility failed to notify Resident #5’s physician of the decline in the condition of the wound to the right ankle or of the development of the Stage 3 PU to the resident’s right ankle.
Review of the Nurse’s Notes from 09/27/19 thru 10/06/19 revealed on 09/27/19 the Assistant Director of Nursing (ADON) readmitted Resident #5 to the facility and documented that the resident had scabbed areas noted on (his/her) bilateral lower extremities, and right outer ankle. The ADON further documented that the resident’s physician was notified; however, there was no documentation in the nurse’s notes of what the physician instructed the ADON to do about the scabbed areas on Resident #5’s lower extremities or right ankle. Further review of the staff nurse’s notes revealed no other documentation from 09/27/19 through 10/06/19 concerning Resident #5’s scabbed area/PU on (his/her) right outer ankle in the nurse’s notes. Interview with the ADON on 10/08/19 at 10:45 AM revealed on 09/27/19 after she readmitted Resident #5 to the facility, she notified the resident’s physician concerning the scabbed area on the resident’s right ankle and lower extremities. She stated Resident #5’s physician instructed her to leave the scabbed areas on the resident’s right ankle and lower extremities open to air and to monitor them. The ADON verbalized she did not write an order or document the physician’s instructions in the nurse’s notes or on the 24-Hour Report/Change of Condition Report concerning Resident #5’s scabbed areas.
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If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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