Failure to Assess, Monitor, and Care Plan for Wounds Leads to Severe Resident Harm
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including end stage renal disease, diabetes, and chronic wounds, was readmitted to the facility and did not receive a complete and accurate initial wound assessment. The admitting nurse documented areas of discoloration on the resident's left inner and right outer ankles but did not identify or measure these as wounds, despite previous records indicating the presence of a scab and a popped blister in the same locations. The nurse did not review prior wound documentation or hospital discharge orders, which included active wound care treatments, and failed to transcribe or continue these orders upon readmission. From the time of readmission, there was no weekly wound monitoring, assessment, or measurement of the affected areas. The wounds were not identified as such until a wound physician assessed the resident two weeks later, at which point both ankle wounds were found to be unstageable due to necrosis. Facility staff did not conduct weekly wound measurements or notify the physician of changes to the wounds from the time they were identified by the wound physician until another assessment was performed over a month later. The facility lacked a designated wound nurse, and charge nurses were responsible for wound care, but no consistent monitoring or documentation occurred during this period. Additionally, the resident did not have a comprehensive, person-centered care plan addressing the wounds. The care plan only referenced discoloration and did not include specific interventions for wound care, monitoring, or physician notification. The lack of accurate assessment, documentation, and care planning resulted in the wounds progressing without appropriate intervention, ultimately leading to the resident's hospitalization for sepsis and surgical amputation of the left lower extremity.