Failure to Assess and Document Worsening Abdominal Wound
Penalty
Summary
The facility failed to assess and document a skin wound for a resident with a colostomy and malnutrition, who was admitted with an abdominal ostomy site showing erythema and skin breakdown. Although the hospital history and physical noted the wound, the facility's admission skin assessment did not indicate any abdominal wounds. Progress notes over several days described the resident's abdominal skin as red, inflamed, excoriated, blistered, and tender, with constant drainage and irretractable pain. Despite these ongoing symptoms and the worsening condition, no weekly wound assessments were completed from admission through the resident's transfer to the hospital and subsequent return. Facility staff confirmed that no wound assessments were performed during this period.