Based on interview, record review, and facility policy review the facility failed to notify the physician timely of a change in medical condition for Resident #42 when she developed weeping legs on 09/30/23. This affected one resident (#42) of three residents reviewed for wound care. The facility census was 47.
Findings include:
Review of the medical record for Resident #42 revealed an admission date of 03/14/20. Diagnoses included hypertensive heart disease, hyperlipidemia, and sick sinus syndrome.
Review of the pressure ulcer risk assessment dated 09/07/23 revealed Resident #42 was not at risk for developing pressure ulcers.
Review of the annual assessment dated 09/26/23 revealed Resident #42's orientation fluctuated. Resident #42 did not require any wound care at the time of the assessment. Resident #42 was dependent for dressing and bathing and set up with cueing assistance for grooming. Resident #42 was incontinent of bladder only and required greater than two times a day toileting assistance.
Review of the nursing progress note dated 09/30/23 at 11:27 P.M. revealed Resident #42 was seen with seeping fluid this evening from her leg. Resident #42 was complaining that it was running into her socks. The nurse cleaned her legs with normal saline solution and applied gauze and abdominal pad dressings and wrapped the leg with more gauze to prevent the seepage from running into her socks. This note was authored by Licensed Practical Nurse (LPN) #503.
Review of nursing progress note dated 10/02/23 at 1:28 P.M. revealed a call was placed to Resident #42's primary care physician related to the seeping in her right lower extremity. New orders were received for Lasix (water pill) 40 milligrams daily for three days; potassium 20 milliequivalents daily for three days; and metoprolol (blood pressure medication) 25 milligrams daily for three days. This note was authored by LPN #502.
Interview on 10/19/23 at 7:35 A.M. with LPN #502 confirmed when she arrived to work on Monday 10/02/23, LPN #503 reported to her that Resident #42 was having trouble with her right lower extremity weeping. LPN #503 did not report it to the physician over the weekend, so LPN #502 did make the phone call. She confirmed Resident #42 had a dressing on her right lower extremity that morning when she came into work.
Interview on 10/19/23 at 10:35 A.M. with Resident #42 revealed no concerns. Resident #42 reported she is very happy with her care. She reported she will see her physician again next week and she hopes her leg is healed.
Interview on 10/19/23 at 12:18 P.M. with the Director of Nursing (DON) confirmed she did get ahold of LPN #502. She reported LPN #502 did inform her that she did place a dressing on Resident #42's leg to make her more comfortable, but she did not call the physician because on 09/30/23 at 11:32 P.M. it was a Saturday night, and she knew the physician would not call back. LPN #502 also reported she did reassess the leg on 10/01/23 which was a Sunday but did not call the physician because she did not feel he would call back.
Review of the undated facility policy titled Assisted Living Licensed Nursing Services Resident revealed the facility will provide stage one or two wound care that includes weekly documentation buy a licensed nurse. The facility will also provide medications and treatment as ordered by a physician and observe changes in a resident's health condition.
This violation represents noncompliance investigated under Complaint Number OH00146156.