Failure to Provide Timely and Consistent Wound Care Leads to Infection
Penalty
Summary
A resident was admitted to the facility with a history of multiple left hip surgeries, including a recent procedure that resulted in a large surgical wound. Upon admission, the admitting RN failed to conduct a complete wound assessment and did not document the presence or condition of the surgical wound in the clinical admission record. Additionally, the RN did not obtain a treatment order for the wound at the time of admission, leaving the wound uncovered and without prescribed care for ten days. The facility's policies required a thorough admission assessment, including skin and wound evaluation, and prompt communication with the attending physician to obtain necessary treatment orders, but these steps were not followed. After a treatment order was eventually obtained, there were further lapses in care. On three consecutive days, the assigned LVNs did not implement the prescribed wound care treatment, as evidenced by blank entries in the medication administration record and confirmation from staff interviews. The wound dressing was not changed during this period, and the wound was left unattended, contrary to the treatment plan. The wound care specialist later confirmed that the wound had not been properly managed and that the dressing had not been changed for several days. As a result of these failures, the resident's surgical wound developed an infection, which was confirmed by laboratory testing and medical evaluation after the resident was transferred to an acute care hospital. The infection was attributed to inconsistent and inadequate wound care, including the lack of a timely treatment order and missed dressing changes. The facility's own staff, including the DON, wound care specialist, and infection preventionist, acknowledged that the required assessments and treatments were not performed according to policy, and that these omissions contributed to the resident's wound infection.