The wound was discovered on September 8, yet the resident's primary physician said he was never informed. His family wasn't contacted either, despite facility policy requiring immediate notification when injuries occur that could require medical intervention.
Resident #8's wound care physician didn't see the injury until September 10 — his first visit with the patient. By September 18, the wound had decreased 44% from when treatment finally began, but the two-day delay violated federal requirements for prompt medical care and family notification.
The facility's director of nursing attempted to call the resident's responsible party on September 8 but didn't answer. She didn't leave a message. She also failed to document the attempted contact in her progress notes, admitting during interviews that she "did not know why she failed to do so."
RN NB told inspectors she was "very busy" and contacted wound care but failed to notify the resident's family or power of attorney. She acknowledged that "failure to notify the physician, and the family could prevent the resident from receiving timely and needed treatment."
The resident's primary physician confirmed he was not informed of the stage 3 pressure area on September 8. He told inspectors he "usually left wound care to the wound care physician since he was the expert in that area."
But the wound care specialist never got the referral until September 10. During his interview, he stated September 10 "was the first time he saw Resident #8" and confirmed "he was not notified prior to that date."
Stage 3 pressure wounds represent serious tissue damage extending through the full thickness of skin. The facility's own wound care nurse had assessed the resident was at high risk for developing pressure areas, yet failed to implement preventive measures that could have avoided the injury entirely.
During interviews, the wound care nurse stated she based her assessment on information from other nurses and "did not receive information that he had a pressure area on that date or since that time." She said it was her expectation that nurses would monitor the resident's skin and notify her of condition changes.
Had she been informed, the wound care nurse said she would have immediately ordered a pressure-relieving mattress and implemented a plan to reposition the resident every two hours to avoid pressure on vulnerable areas.
The facility's own policy, revised in November 2016, explicitly requires immediate notification when residents experience injuries with potential for requiring physician intervention. The policy states the facility must "immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority resident representatives when there is an accident involving the resident which results in an injury and has the potential for requiring physician intervention."
The policy further mandates notification for "significant change in the residence physical, mental, or psychosocial status that is a deterioration in health, mental, or psychosocial status, and either life threatening conditions or clinical complications."
Federal inspectors found the facility failed to follow its own written procedures. The breakdown occurred at multiple levels — the bedside nurse who discovered the wound, the director of nursing who made incomplete contact attempts, and the system that should have ensured the resident's physician received critical information about a serious injury.
The resident sat in his wheelchair at the nursing station desk while staff around him knew about his untreated stage 3 wound. His family remained unaware. His doctor continued routine care without knowing about the serious pressure injury that required immediate intervention.
The wound care physician's assessment showed the injury responded well once treatment began, decreasing nearly half its size within eight days. But those first 48 hours of delayed care represented a violation of the resident's right to prompt medical attention and family notification during health crises.
The case illustrates how communication failures in nursing homes can delay critical medical care, even when staff recognize serious injuries. The resident's wound eventually healed with proper treatment, but only after a two-day gap that violated federal care standards and the facility's own policies for protecting residents' health and keeping families informed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peach Tree Place from 2025-09-19 including all violations, facility responses, and corrective action plans.