Failure to Timely Identify, Assess, and Treat Wounds Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure timely identification, assessment, monitoring, and treatment of a right great toe ulcer/abrasion for a resident with severe cognitive impairment, functional quadriplegia, and a history of toe infections. Despite multiple skin audit reports and documentation by nurse aides indicating a bandage or skin integrity issue on the resident's right great toe over a two-month period, there was no corresponding nursing assessment, monitoring, or physician-ordered treatment documented in the medical record. The resident's care plan and physician orders required regular skin and foot assessments, but these were inconsistently completed, and the right great toe wound was not properly evaluated or treated by nursing or wound care staff. The wound was ultimately discovered by the resident's wife, who noticed a foul odor and persistent bandage, prompting a nurse to remove the dressing and find signs of infection. The resident was subsequently sent to the hospital, where he was diagnosed with osteomyelitis and sepsis, requiring intravenous antibiotics and a five-day hospital stay. Additionally, the facility failed to complete wound treatments as ordered for another resident with dementia and chronic kidney disease, who had a physician's order for daily wound care to a left heel pressure ulcer. Review of the treatment administration records revealed that nursing staff did not perform the ordered wound care on multiple documented dates over a two-month period. The care plan for this resident specifically included performing treatments as ordered by the physician, but these interventions were not consistently carried out. Interviews with facility staff, including the DON, LPNs, and wound nurse, confirmed a lack of awareness and documentation regarding the presence and treatment of wounds, as well as missed treatments. Facility policies required direct care staff to report skin integrity issues and for nurses to assess and document wounds, but these protocols were not followed, resulting in actual harm to at least one resident and affecting two of three residents reviewed for wounds.