Failure to Assess and Document Post-Operative Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards and provider orders for a resident who was admitted with a post-operative surgical wound following a right hip hemiarthroplasty. The facility's policy required a total skin assessment on admission and weekly for four weeks by a licensed nurse, but this was not completed for the resident. The care plan did not include wound care for the surgical incision at the time of the state agency review, and there was no documentation of surgical wound assessment, care, or treatment from admission until several days later. The resident reported that staff had not changed or examined the bandage since admission, and a surveyor confirmed the presence of an unchanged dressing during an interview and observation. Further review revealed that there were no provider orders or documentation for post-operative incision care in the resident's record, despite clear instructions from the hospital discharge summary regarding wound care and dressing removal. Nursing staff and the Director of Nursing acknowledged that the surgical wound was not identified or assessed upon admission, resulting in the absence of a treatment record, daily wound checks, or a care plan for the incision. The facility did not follow its own wound assessment procedures or the discharge instructions, and the required assessments and documentation were not performed until after the deficiency was identified by surveyors.