Failure to Timely Assess, Identify, and Treat Resident Wound Infection
Penalty
Summary
The facility failed to provide appropriate skin assessments, timely identification of a new wound, and necessary medical treatment for a resident with significant comorbidities, including vascular dementia, hemiparesis, and hemiplegia. The resident was admitted with severe cognitive impairment and was care planned for comfort measures, with interventions to monitor and report changes in skin condition. Despite these interventions, there were no weekly skin assessments documented, and the process for skin checks relied on shower team observations rather than scheduled nursing assessments. A new wound on the resident's left heel was first noted as a red area by a nurse aide during a shower, but this information was not effectively communicated or documented by the assigned nurse. The wound was later identified as an open, unstageable area by the Wound Nurse, who treated it according to standing orders and notified the Wound Nurse Practitioner the following day. The Wound Nurse Practitioner found the wound to be deep, necrotic, and likely of diabetic etiology, ordering a wound culture, labs, and x-ray. However, there was a breakdown in communication regarding the results of the wound culture and sensitivity, which showed infection. The Wound Nurse Practitioner was incorrectly informed that the culture was negative and was not provided with the actual results, delaying the initiation of antibiotic therapy. Further interviews revealed that the NP and Medical Director were not notified of the new heel wound or the positive culture results in a timely manner. The Wound Nurse stated that lab results were faxed to providers only after all results were received, and the DON confirmed that the Wound Nurse Practitioner should have been shown the positive culture results during her visit. This lack of communication and failure to follow up on lab results led to a delay in the resident receiving appropriate antibiotic treatment for the infected wound.