Failure to Perform Ongoing Wound Monitoring and Care
Penalty
Summary
A resident with a history of heart failure and hip fracture, who was cognitively intact and required maximum assistance with mobility and toileting, was admitted with a surgical incision on the left hip. The care plan did not include documentation regarding wound care, despite physician orders specifying Mepilex dressing changes every two to three days. The electronic health record (EHR) and treatment administration record indicated dressing changes were performed every three days, but there was a lack of ongoing wound assessment documentation, particularly after the resident returned from a hospital stay for an abscess and active drainage at the surgical site. Interviews revealed that nursing staff did not assess or change the dressing as ordered after the resident's hospital readmission, and the director of nursing was unaware of this lapse. Observations confirmed that wound assessments and dressing changes were not consistently documented or performed according to provider orders. Facility policy required head-to-toe skin assessments upon admission and readmission, with weekly follow-up, but these were not documented for the resident after their return from the hospital.