The wound care consultant at CareOne at Parsippany recommended the additional treatment in September and October 2024 for a resident with a left foot wound that had initially been healing but then deteriorated. The resident also developed edema, or swelling.
But facility staff never documented any follow-up with the physician about these recommendations, inspectors discovered during a November 7 complaint investigation.
The facility's own policy requires that attending physicians be "timely apprised of the findings and recommendations of consultants and specialists." Another policy states that physicians must guide care plans "especially when wounds are not healing as anticipated."
When inspectors interviewed the Assistant Director of Nursing, she could not recall specifics about the wound care consultant's recommendations from September and October 2024. She said she would need to review the resident's medical record to provide additional information.
The ADON noted that the wound care consultant no longer worked at the facility.
LPN #1 told inspectors that worsening wounds should be reported to both the physician and wound care consultant for treatment orders. The LPN remembered the resident and the left foot wound that received wound care, and recalled that both the wound care consultant and infectious disease specialist were consulted.
However, like the ADON, the LPN could not recall specifics about the consultant's recommendations or any communication with the physician from September and October 2024.
The Director of Nursing explained the proper protocol to inspectors. When a resident has a worsening wound, she said, an incident report should be completed, it should be reported to the physician and wound care consultant for treatment orders, and the resident or responsible party should be notified.
The physician should be told about wound care consultant recommendations so they can determine whether they agree or disagree with the recommendations, the DON said. This notification should be documented in the electronic medical record under progress notes.
When inspectors informed facility leadership about the lack of documentation regarding physician follow-up on the wound care consultant's recommendations, the DON said she would review the resident's medical records.
Later that afternoon, the DON and Licensed Nursing Home Administrator met with the surveyor. The DON reported that her review found no incident report for the resident's wound, no physician progress notes, and no documentation of notification to the primary physician regarding the wound care consultant's recommendations for possible antibiotics and bone scan.
The facility provided no additional information to inspectors.
The wound care consultant's recommendations came at a critical time in the resident's care. The foot wound had been healing initially but then worsened, and the resident developed swelling. Despite this deterioration and the consultant's specific recommendations for antibiotics and a bone scan, there was no evidence that the attending physician was ever informed.
Facility policies reviewed by inspectors emphasized the importance of physician involvement in wound care. One policy states that during resident visits, physicians must "evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds."
The same policy requires physicians to "guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions."
The breakdown in communication between the wound care consultant and the attending physician violated multiple facility policies designed to ensure coordinated medical care. The facility's policy on physician progress notes, last revised in February 2008, requires that notes "reflect the resident's progress and response to his or her care plan, medications, etc."
State inspectors found that CareOne at Parsippany failed to follow its own procedures for ensuring attending physicians receive consultant recommendations. The facility's policy on physician orders for consultation, revised in January 2022, specifically requires timely communication of consultant findings and recommendations to attending physicians.
The case illustrates how communication breakdowns between different medical providers can leave residents without recommended treatments. Despite having policies in place to prevent such lapses, facility staff failed to document any effort to inform the physician about the wound care consultant's recommendations for antibiotics and bone scan when the resident's condition worsened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careone At Parsippany from 2025-11-07 including all violations, facility responses, and corrective action plans.