Failure to Ensure Timely Wound Care and Specialist Follow-Up
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely medical appointments and debridement treatments for a resident with a history of gangrene and recent toe amputation, resulting in the worsening of a wound and subsequent hospitalization. The resident, who spoke Korean and had a high cognitive status, was scheduled for follow-up wound care and debridement but was sent to the wrong office for a critical appointment. This error led to a delay of one week before the resident could be seen by the appropriate wound surgeon, during which time the wound deteriorated, ultimately requiring further surgical intervention, including debridement and amputation of an additional toe. The clinical record review revealed that the resident had multiple orders and recommendations for wound care, including specific dressing changes, offloading interventions, and follow-up appointments with wound care specialists and podiatry. Despite these orders, documentation showed missed appointments, lack of timely follow-up, and a failure to implement recommended treatments such as vancomycin, which was noted in progress notes but never ordered or administered. Additionally, the resident was noted to be performing self-care on the wound, which was identified as delaying healing, and there was insufficient use of translation services to address the resident's language barrier, despite the availability of such resources. Interviews with facility staff, including wound nurses, the DON, and the unit clerk, confirmed lapses in communication, scheduling, and follow-up. The unit clerk acknowledged sending the resident to the wrong location, and both wound nurses were unclear about the specifics of the resident's care and did not utilize available translation services. The DON was aware of the language barrier and the resident's self-care but did not ensure the use of interpreter services. Facility policies required weekly evaluation of skin alterations and prompt response to changes in condition, but these were not consistently followed, contributing to the resident's decline and need for hospitalization.