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F0684
E

Failure to Assess and Measure Surgical Wounds as Ordered

Saint Petersburg, Florida Survey Completed on 06-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that surgical wounds were properly assessed and measured for three residents, as required by physician orders and facility policy. For one resident with a history of rhabdomyolysis, open wound on the right hip, and other significant comorbidities, documentation showed inconsistent and missing wound measurements. Although initial wound sizes were recorded, subsequent weekly wound observation tools lacked measurements, and there were gaps in assessment documentation. The care plan specifically required weekly documentation of wound measurements, but this was not consistently followed. Interviews with staff and the DON confirmed that wound measurements were not performed as required, and that there was a misconception among staff that surgical wounds did not need to be measured. Another resident with diagnoses including sepsis, cellulitis, and a diabetic foot ulcer had physician orders for daily wound care to a surgical incision on the left foot. However, the skin evaluation and progress notes lacked wound measurements and descriptions. The DON acknowledged that the required wound observations and measurements were missing and that there was no baseline care plan documented in the assessment section of the medical record. The absence of wound measurements and descriptions was confirmed during interviews and record review. A third resident with multiple surgical incisions and complex medical history also did not have wound measurements or descriptions documented upon admission or in subsequent evaluations. The skin evaluation and nursing admission screening noted the presence of wounds but failed to provide objective data such as size or description. The DON verified that wound evaluations should have been completed using the appropriate tool and that baseline care plans were not present in the medical record. Facility policies required thorough documentation of wound assessments and baseline care plans within 48 hours of admission, but these requirements were not met for the residents involved.

See complete original report
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