Failure to Assess, Monitor, and Treat Surgical Wounds
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and intervention for wounds in three residents with recent amputations or surgical wounds. One resident was admitted with a right below the knee amputation (RBKA) and had no documented assessment or monitoring of the surgical site for 14 days after admission, despite hospital discharge instructions requiring daily inspection. The initial skin assessment did not mention the surgical wound, and subsequent assessments lacked details such as measurements, presence of staples or sutures, and peri-wound condition. There were no physician orders or care plan interventions addressing wound monitoring until two weeks post-admission, by which time the wound had dehisced and become infected, ultimately requiring further surgery. Another resident with a right above the knee amputation (AKA) did not have the surgical site assessed or monitored until three days after admission, and wound monitoring orders were not initiated until the fourth day. The admission skin assessment failed to mention the surgical site, and the care plan did not include specific interventions from the hospital discharge instructions, such as the use of a stump shrinker or showering guidelines. The resident reported that nurses checked the incision every other day, but documentation and orders did not reflect consistent monitoring from admission. A third resident with a left great toe amputation had an open wound that was not consistently assessed or treated according to physician orders. The skin assessment was completed four days after admission, and there was no order for wound dressing or treatment for the left great toe, despite wound care being observed and the resident expressing concern about inconsistent dressing changes. Documentation showed only weekly measurements by the wound nurse, and the care plan lacked specific interventions for the wound. Interviews with staff confirmed that wound assessment and monitoring were not routinely performed as required, and there was confusion regarding wound care orders.