Failure to Identify and Address Deficiencies in Wound Assessment and Management
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to deficiencies in wound assessments, specifically for non-pressure (surgical) wounds. Over a period of several weeks, three residents with surgical wounds did not have consistent or comprehensive wound assessments completed. For example, one resident with a surgical wound on her left foot did not have a comprehensive wound assessment documented for nearly two weeks, while another resident had a gap of over two weeks between wound assessments. A third resident also lacked documentation of a comprehensive wound assessment for a surgical wound during the review period. These lapses resulted in at least one resident developing a worsening infection in a wound, which delayed necessary treatment and care. Despite being informed by the certified wound nurse practitioner that wound assessments were not being completed consistently, the DON did not bring these concerns to the quality team or initiate an action plan to address the issue. The QAPI committee had been monitoring pressure-related skin issues but was not addressing non-pressure related skin concerns. At the time of the survey, the facility's quality action plans did not include any measures for assessing or monitoring skin-related issues, and the QAPI committee had not yet developed or implemented a plan to address the identified deficiencies in wound management.