Failure to Assess Wound and Obtain Wound Care Orders
Penalty
Summary
The facility failed to assess a wound and obtain appropriate wound care orders for a resident who was admitted following right ankle surgery for osteomyelitis and cellulitis. Upon admission, there was no documentation of wound care orders or clarification of the resident's weight-bearing status in the physician orders. The resident reported that their dressing had not been changed since arrival and that no one had examined the wound. Nursing staff confirmed that no dressing change or wound assessment had occurred since admission, and there was no order specifying the resident's weight-bearing status. Further interviews revealed uncertainty among staff regarding the resident's transfer status, with some believing the resident was non-weight bearing but lacking confirmation. The Rehab Services Director later produced hospital discharge paperwork indicating a non-weight bearing order, but this information had not been incorporated into the facility's orders or communicated to the care team. As a result, the resident did not receive the necessary wound care or clear guidance on mobility restrictions as required by their condition and post-surgical needs.