Failure to Provide Timely and Comprehensive Wound Assessment and Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following the development of a wound. The resident, who had a history of dementia and an ankle fracture treated with open reduction and internal fixation (ORIF), was admitted to the facility and identified as being at risk for pressure ulcers. Despite this risk, there was no care plan in place for pressure injury prevention prior to the discovery of the wound. Upon identification of the wound, the facility did not document a comprehensive assessment to determine the wound type, nor did they specify the wound's location in initial evaluations. The facility's documentation was inconsistent and incomplete regarding the evaluation, assessment, treatment, and outcomes of the resident's wound. The wound was initially documented as an unstageable pressure injury without a clear location, and subsequent records failed to clarify whether the wound was pressure-related or associated with the resident's orthopedic hardware. There was also a lack of timely consultation with an orthopedic specialist when hardware was observed protruding from the resident's skin. Physician assessments did not include comprehensive wound evaluations or documentation of treatment progress, and the wound care plan was not updated until after the wound was discovered. Interviews with facility staff revealed that oversight of the wound care program was unclear, with responsibilities divided between the wound nurse, DON, and a newly hired nurse practitioner. The medical director acknowledged awareness of the hardware protrusion but did not provide documentation of a direct assessment. The wound nurse was unavailable for interview, and the facility was unable to provide evidence of timely or thorough physician evaluation of the wound. Ultimately, a nurse practitioner later determined the wound was related to the internal orthopedic device, not pressure, but this assessment occurred well after the initial deficiency in care and documentation.