Failure to Provide Timely Wound Care Following Notification from Dialysis Clinic
Penalty
Summary
Facility staff failed to provide necessary care and services and did not respond appropriately to changes in a resident's condition when wounds were identified and treated by a dialysis clinic. The dialysis staff discovered wounds on the resident's right foot, including missing skin and black discoloration, and notified the facility on the same day. Despite this notification, the facility did not assess or initiate treatment for the wounds until five days later. The resident reported that only the dialysis staff had changed his dressing, and no one from the facility had checked or treated the wounds during this period. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's foot wounds. The unit manager and wound care nurse were unaware of any issues, and there was no evidence in the 24-hour nursing reports or electronic medical record that the physician had been notified or that any interventions had been implemented. The facility's policies required weekly skin audits and prompt intervention for identified skin conditions, but the weekly skin assessment completed after the resident returned from dialysis did not document the wounds, and the wound care nurse could not confirm if the assessment had actually been performed. The resident had a history of end-stage renal disease and severe cognitive impairment. Observations at the dialysis center confirmed that the same dressing applied by dialysis staff remained unchanged for several days, and the facility's wound care physician did not receive a consultation order until five days after the initial notification. Facility leadership acknowledged that staff failed to ensure appropriate wound care, monitoring, and follow-up actions, despite being informed of the resident's condition by the dialysis clinic.