Failure to Provide Wound Care and Skin Assessments Resulting in Neglect and Amputation
Penalty
Summary
A facility failed to protect a resident's right to be free from neglect by not providing daily wound care or regular skin assessments over a period of nearly one month. The resident, who had significant medical conditions including quadriplegia, kidney disease, cirrhosis, and a history of pressure ulcers, was dependent on staff for mobility and personal hygiene. Despite being at high risk for pressure ulcers and having documented wounds, the facility did not ensure that wound care orders were entered into the electronic medical record (EMR), nor did nursing staff consistently provide or document wound care and skin assessments as required by facility policy. The resident had multiple wounds, including a Stage IV pressure ulcer on the left ankle and a surgical wound following a right below-knee amputation (BKA). Wound care physician assessments and outpatient clinic notes documented the presence and worsening of these wounds, with evidence of infection, necrosis, and exposed bone. Nursing staff interviews revealed a lack of awareness or follow-through regarding wound care orders, with some staff stating they did not provide care due to missing orders in the EMR. The Assistant Director of Nursing (ADON) acknowledged responsibility for entering wound care orders but admitted to missing this task, resulting in the absence of documented wound care for the left ankle. The resident's condition deteriorated, with observations of soiled dressings, malodor, and purulent drainage. The lack of wound care and monitoring led to the development of osteomyelitis and septic shock, necessitating hospitalization and a left BKA. Interviews with staff, the wound care physician, and the hospital case manager confirmed that wound care was not performed as ordered, and concerns raised by outside care teams were not addressed by facility staff. Facility policies required weekly skin assessments and prompt notification of physicians for changes in wound status, but these were not followed, resulting in neglect and significant harm to the resident.