Failure to Complete Comprehensive Wound Assessments and Timely Physician Notification
Penalty
Summary
A resident was admitted to the facility with a wound on her left abdomen, along with other medical conditions including rheumatoid arthritis, type 2 diabetes with polyneuropathy, and heart failure. Upon admission, the wound was noted to have exudate and odor, but the initial assessment was performed by an LPN, which is not in accordance with the Wisconsin Nurse Practice Act that requires an RN to conduct assessments. There was no evidence that an RN reviewed or signed off on the LPN's observation, nor was there documentation that a provider was notified about the wound odor at that time. Throughout the resident's stay, the facility failed to complete ongoing comprehensive wound assessments as required by professional standards and facility policy. Documentation was inconsistent and incomplete, lacking critical wound characteristics such as type, bed description, surrounding tissue appearance, drainage, and odor. The wound increased in size and developed a foul odor, but there was no timely notification to the physician regarding these changes. Multiple staff interviews confirmed that changes such as increased wound size, odor, and drainage should have prompted provider notification, but this did not occur. The resident's condition deteriorated, with the wound developing thick, green/brown drainage, increased pain, and redness. Eventually, the resident requested to be sent to the emergency department, where she was diagnosed with a wound infection and septic shock. Hospital records confirmed the presence of multiple organisms in the wound culture. The lack of comprehensive wound assessment, failure to follow professional standards, and delayed physician notification directly contributed to the resident's readmission to the hospital with a serious wound infection.