Failure to Assess and Monitor Wounds Resulting in Wound Deterioration
Penalty
Summary
The facility failed to assess, monitor, and provide appropriate care for a resident with a non-pressure abdominal wound and a newly developed lower extremity (LE) ulcer. Upon admission, the resident had a dehisced surgical wound to the midline abdomen and amputated toes on the right foot, with diagnoses including peripheral vascular disease and diabetes. The admission assessment noted the presence of the abdominal wound and wound vac, but did not include wound measurements or detailed wound characteristics. Hospital transfer orders specified wound vac settings and dressing change frequency, but these were not transcribed into the facility's records, and no care plan interventions were developed to address the wound or minimize further breakdown. From admission, there was no documentation of wound care, assessment, or monitoring for the abdominal wound until 24 days later, nor for the right calf wound until 13 days after admission. The Treatment Administration Records (TARs) and electronic medical record (EMR) lacked any entries regarding the abdominal wound, wound vac, or required dressing changes during this period. The resident developed a new ulcer on the right posterior calf, which was not present on admission and was only identified after it had progressed to 75% slough and required mechanical debridement. Staff interviews confirmed that the abdominal wound was not assessed or treated because staff were unaware of its presence, and the necessary wound care orders were not implemented. When the abdominal wound was finally assessed 24 days after admission, it had increased in size, indicating a worsening condition. The wound care consult documented the wound's increased area and provided new treatment recommendations. The Director of Nursing acknowledged that the facility failed to identify and treat the wounds in a timely manner, and that the right LE ulcer should have been detected earlier, especially given the resident's need for maximal assistance with lower body dressing.