Failure to Provide Timely Follow-Up and Communication for Surgical Wound Care
Penalty
Summary
The facility failed to provide timely follow-up care for a resident with a left foot surgical wound. The resident, who had a history of diabetes, chronic kidney disease, and recent amputations, was admitted with orders for IV antibiotics and follow-up with a surgeon and infectious disease. There was no care plan for the surgical wound, and documentation of the wound's condition or treatment was missing from admission until several days later. Orders for wound care and wound vac application were not consistently documented as completed, and there was no explanation for missed treatments. Additionally, there was no evidence that the resident attended a scheduled surgeon appointment or that the surgeon was notified of changes in the wound's condition, despite worsening symptoms and positive wound cultures for infection. Progress notes indicated that the resident's wound deteriorated, showing signs of infection, bone exposure, and purulent discharge, yet there was still no documentation of timely notification to the surgeon. The resident was eventually transferred to the hospital for evaluation, and only after further decline was an appointment with the surgeon arranged. Interviews with facility leadership confirmed the lack of documentation and follow-up, as well as the failure to notify the surgeon of significant changes in the resident's wound status.