Failure to Monitor and Document Surgical Wound Leading to Infection and Hospitalization
Penalty
Summary
The facility failed to adequately monitor and document the condition of a surgical wound for one resident who had undergone amputation of the right fingertips due to dry gangrene. Upon admission, the resident had a dressing on the right hand that was not to be removed until a follow-up with the surgeon. After the initial follow-up, daily wound care was ordered and documented as completed on the Treatment Administration Record (TAR), but there was no corresponding documentation in the nurse progress notes regarding the wound's condition or any changes observed during this period. Subsequent surgical follow-ups revealed the development of a large blister and signs of soft tissue infection on the resident's right hand, leading to new wound care orders and antibiotics. While the TAR indicated that wound care was performed, there was no documentation showing that the wound was monitored for increased redness or signs of worsening infection as ordered. Nurse notes contained only brief references to the wound's appearance and infection status, with no detailed assessments or ongoing monitoring documented, especially in the days leading up to the resident's transfer to the hospital for a worsened infection. Interviews with facility staff revealed inconsistent practices and a lack of clarity regarding wound monitoring responsibilities, particularly for surgical wounds. Staff members were either unfamiliar with the resident's wound or had not observed it directly, and the Director of Nursing stated that wound observation forms were not used for surgical incisions at the time. The lack of thorough assessment and documentation contributed to the resident's condition worsening, ultimately resulting in hospitalization and further amputation.