Failure to Provide Timely Wound Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. For one resident with a recent left below-the-knee amputation, the facility did not provide timely, consistent, and effective monitoring or appropriate documentation of the surgical incision. Although the initial skin assessment documented the incision as well approximated, subsequent wound care assessments failed to address the amputation site. When the resident and physician identified signs of infection, antibiotics were ordered, but there was a delay of two days before these medications were entered into the electronic medical record and administered. Throughout this period, nursing documentation did not consistently reflect monitoring of the incision for signs of worsening infection, despite the resident being on antibiotics. The resident ultimately required hospitalization for an infected amputation site, where she underwent further surgical intervention and did not return to the facility. Additionally, the facility failed to obtain timely wound care orders for another resident admitted with a skin tear to the left lower leg. Upon admission, the nursing note documented a single wound, but did not address a larger skin tear observed later. The admitting nurse did not change the dressing, citing the absence of wound care orders, and the wound care nurse delayed entering the necessary orders into the electronic medical record. As a result, the resident did not receive appropriate wound care or documentation for two days after admission, and the wound care provided was not properly documented. Staff interviews confirmed lapses in communication and documentation. The wound care nurse stated she was not notified of changes to the amputation site and did not follow wounds unless issues were reported. The director of nursing and other nursing staff described expectations for wound monitoring and documentation that were not met in these cases. The deficiencies were directly related to failures in timely assessment, documentation, and implementation of physician orders for wound care and infection management.