State Findings:
Based on interview, record review, and facility policy review, it was determined that the facility failed to notify the physician of a change in condition for one (1) of three (3) sampled residents reviewed for notification of changes in condition (Resident #41).
Review of the facility policy, titled, Change of Condition, dated 11/06/2019, was completed. The policy indicated that a significant change in the resident’s physical, mental or psychosocial status would be relayed to the physician.
Review of the Nursing Admission Skin Assessment, dated 07/05/2021, revealed that Resident #41 had no open areas.
Review of the Wound Management Observation History dated 07/08/2021, revealed a pressure ulcer to the left hip measuring 2.5 cm (centimeters) x 1.5 cm. The next measurement recorded was dated 08/09/2021. The wound measured 4.6 cm x 4 cm.
Review of the Progress Notes for Resident #41, from 07/05/2021 through 08/11/2021, revealed no indication that the physician was notified of the change in the size of the wound or Resident #41’s refusal of wound treatments and measurements.
Interview with Licensed Practical Nurse (LPN) #2, on 08/11/2021 at 5:31 PM, revealed she was identified as the facility wound nurse. LPN #2 stated Resident #41 refused wound measurements and would not let her measure the wound. She stated the wound was measured about once a month, as Resident #41 allowed the floor nurse to complete the measurement. LPN #2 further stated Resident #41’s wound had gotten worse, and she had not spoken to Resident #41’s physician about the refusals or the worsening of the wound.
Interview with the Director of Nursing (DON), on 08/12/2021 at 9:30 AM, revealed she had spoke with Resident #41’s physician, on 08/11/2021 about the worsening wound, and Resident #41’s refusal of care. The doctor should have been called when the wound reopened, when it was measured as worse, or that [Resident #41] was refusing [care]. The physician was called to request a wound treatment on 07/08/2021, but there was no further communication about the refusal of treatments or the wound worsening.
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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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Personal Note from NHA-Advocates
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