Failure to Provide Appropriate Wound Care and Monitoring Resulting in Infection
Penalty
Summary
A resident with a recent total right hip replacement and additional non-operable fractures was admitted to the facility for rehabilitation. Upon admission, the resident was dependent for bed mobility and required assistance for all activities of daily living. The hospital discharge documentation indicated the surgical incision was healing well, and the resident had previously used a PureWick device and bedside commode to keep the incision clean and dry. However, at the facility, the resident was placed in adult briefs, the surgical incision was left uncovered, and staff did not consistently assist the resident to the toilet, resulting in prolonged periods in soiled briefs. The resident expressed concerns about wound infection risk and requested toileting assistance, but her preferences were not accommodated due to her transfer needs. The facility's records lacked initial and ongoing assessments and descriptions of the surgical incision site, as well as documentation of treatment orders or physician clarification for wound care. Although care plans referenced the surgical incision and the need to provide treatment per physician order, there were no specific interventions or precautions documented to protect the wound from contamination. When drainage and signs of infection developed at the incision site, there was insufficient documentation of physician notification, wound assessment, or implementation of appropriate wound care, such as covering the draining wound. Progress notes indicated ongoing drainage, foul odor, and infection, but lacked detailed wound descriptions and timely communication with the physician. Despite the resident's increasing symptoms and the development of a wound infection, the facility did not document the initiation of appropriate wound care interventions or consistent monitoring. The resident's condition worsened, leading to a hospital readmission where the wound was found to be infected with multiple bacteria, requiring surgical intervention. Facility policies required prompt assessment, documentation, and physician notification for changes in condition, as well as enhanced barrier precautions for wounds, but these were not followed, resulting in actual harm to the resident.