Failure to Assess and Manage Wounds Resulting in Amputation
Penalty
Summary
Licensed nursing staff failed to provide wound care in accordance with professional standards and the resident's comprehensive care plan for a resident with multiple comorbidities, including end stage renal disease, diabetes, and chronic wounds. Upon readmission from the hospital, the resident's left inner ankle and right outer ankle were documented as areas of discoloration rather than wounds, despite previous records indicating the presence of a scab and a popped blister in those locations. The admitting nurse did not review prior wound documentation or hospital discharge orders, which included active wound care treatments, and did not transcribe or implement these orders. As a result, no wound care was provided, and the areas were not measured or monitored as wounds. From the time of readmission, there was no weekly wound monitoring, assessment, or measurement for the affected areas. Nursing staff did not notify the physician of changes or deterioration in the resident's condition, and there was no documentation of wound progression until a wound physician assessed the resident two weeks later, identifying both wounds as unstageable due to necrosis. The facility lacked a designated wound nurse, and charge nurses were responsible for wound care, but did not perform or document required assessments. The interdisciplinary team did not review the wounds, as they were not recognized as such by nursing staff. The lack of appropriate wound assessment, monitoring, and intervention led to the development of necrotic wounds on the resident's lower extremities. This resulted in the resident being admitted to an acute care hospital for sepsis related to necrotizing fasciitis, ultimately requiring surgical amputation of the left lower extremity. Facility policies and job descriptions required nursing staff to demonstrate competency in wound care, assessment, and documentation, but these standards were not met in this case.