Failure to Assess and Provide Care for Surgical Wound with Sutures
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and provide care for a surgical incision with sutures for one resident admitted from an acute care hospital. The resident was admitted with a surgical incision on the left lateral thoracic region, which had three stitches and an intact dressing. Transfer orders from the hospital specified that wound care should follow current recommendations and standard nursing protocols. The admission skin assessment documented the presence of the surgical incision and dressing, but subsequent progress notes indicated that the skin issue had not been evaluated. From admission until several months later, there was no evidence that the facility assessed or monitored the surgical wound, nor was there a baseline care plan developed to address the wound or the presence of sutures. The omission persisted until the resident's outpatient dialysis clinic notified the facility about the sutures, prompting the wound care nurse to assess the site and remove the stitches. Interviews confirmed that the wound was in a location easily visible during routine care, and the resident required maximum assistance with activities of daily living, making the oversight notable. The Director of Nursing verified that licensed nurses were required to perform full skin assessments on admission, readmission, and weekly if no concerns were present, and that direct care staff were expected to assess skin during bathing, changing, or repositioning. The facility's failure to follow these protocols resulted in a delay in identifying and providing care for the surgical incision and sutures, as confirmed by both the DON and the administrator.
Plan Of Correction
F0684-- Quality Of Care Immediate Corrective Action: On 09/02/2025, treatment care was initiated immediately for Resident #10 Surgical site. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents' wounds to ensure that treatment care, orders, and care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for immediately initiating treatment care and orders, developing, reviewing, and updating care plans for wounds and surgical sites. Monitoring of Corrective Action: The DON or their designee will review treatment orders for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents' wounds to ensure that treatment care, orders, and care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for immediately initiating treatment care and orders, developing, reviewing, and updating care plans for wounds and surgical sites. Monitoring of Corrective Action: The DON or their designee will review treatment orders for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 F0684