Failure to Notify Physician and Care Plan for Re-Opened Surgical Wound
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a re-opened surgical wound. Upon admission, the resident had a healing surgical wound on the abdomen following a hernia repair, and reported that the site had re-opened about a month prior. The resident stated that staff were not providing any treatment for the re-opened wound. Observation confirmed a small, open wound near the navel, with no dressing applied and no signs of infection. The registered nurse acknowledged seeing the wound previously but had not notified the physician or obtained a treatment order. Further interviews revealed that the Assistant Director of Nursing was unaware of the resident's wound and had not been notified, despite being responsible for tracking wounds in the facility. The nurse involved stated that she had only documented the issue on the communication board and did not contact the physician, as she did not observe signs of infection. The MDS Coordinator also confirmed that the wound was not included in the care plan or the facility's list of residents with current skin breakdown, and was only made aware of the wound the previous night. Record review showed no physician orders or treatment administration records for the wound, and the comprehensive care plan lacked individualized goals or interventions for the surgical wound. Facility policies required notification of the physician and updates to the care plan for changes in condition, as well as consistent monitoring and documentation of wounds, but these protocols were not followed in this case.