Failure to Provide Timely Wound Care and Communication for Post-Operative Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and appropriate wound care, accurate documentation, and effective communication regarding a post-operative surgical site for a resident admitted with multiple complex medical conditions, including a recent lumbar fusion, right hip fracture, diabetes, and adrenal insufficiency. Upon admission, the initial skin assessment did not document the resident's post-operative back incision, despite its presence and the need for ongoing care. Physician orders for wound care to the central lower back were not implemented until the third day after admission, and there were missed dressing changes on subsequent days, with no corresponding nursing notes to explain the omissions. The resident reported increased pain and drainage from the back incision, and there was evidence of wound dehiscence documented in progress notes. However, the facility failed to notify the physician or nurse practitioner of the change in the wound's condition, and the provider was not made aware of the dehiscence. The resident and her family had to advocate for wound assessment and care, and ultimately, the back surgeon's office instructed the resident to seek emergency care after reviewing a photo of the wound. The lack of timely wound care, incomplete documentation, and failure to communicate changes in the wound's condition resulted in the resident developing a surgical site infection that required hospital admission, surgical washout, intravenous antibiotics, and an extended course of oral antibiotics. Facility policy required wound treatments to be provided according to physician orders and for nurses to notify the physician in the absence of orders, but these procedures were not followed in this case.