Failure to Assess, Document, and Treat Surgical Wound
Penalty
Summary
The facility failed to assess, document, and treat a surgical wound for one resident with a history of multiple fractures and recent surgical interventions. The resident was observed with a mesh pad covering a black area on the left ankle, which had reportedly been in place for about a month. Despite the presence of this surgical site, there were no physician or surgeon orders regarding its care, and the site was not mentioned in weekly skin checks or documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The care plan referenced potential or actual skin impairment but did not include specific interventions or follow-up instructions for the left ankle surgical site. Interviews with staff, including the DON and an LPN, confirmed that the area had not been recently assessed or monitored, and the wound specialist had not provided recent recommendations. The facility's documentation policy requires accurate and complete records of resident care, but the medical record lacked sufficient detail about the left ankle surgical site. This lack of assessment, documentation, and treatment for the surgical wound constituted a deficiency in providing appropriate care according to orders, resident preferences, and goals.