Failure to Implement Surgical Wound Care Orders
Penalty
Summary
The facility failed to implement wound care orders for a resident who was admitted with pelvis fractures, muscle weakness, and recent surgical repairs, including a suprapubic catheter and surgical wounds to the hips and pubic area. Upon review, it was found that the hospital transfer orders specified surgical site wound care with dressing changes every 2-3 days for the bilateral pubis area, but these orders were not transcribed into the resident's medical record or carried out by staff. The clinical admission evaluation did not document the presence of surgical wounds or the need for wound care, and the care plan only generally referenced wound care without specific implementation of the required dressing changes. During observation and interview, the resident reported that the dressing on their pubic area had not been changed for 2-3 weeks and that the current dressing was from a previous hospital visit. The dressing was visibly soiled with dark yellow drainage. Staff interviews confirmed that the wound care orders from the hospital were not processed or implemented, and staff acknowledged the importance of monitoring wounds for signs of infection. The Director of Nursing stated that staff are expected to review and implement provider orders and update care plans accordingly, but this did not occur in this case.