Failure to Provide Timely Wound Care and Change in Condition Response
Penalty
Summary
The facility failed to provide necessary care and services to two residents, resulting in harm. For one resident with a history of myasthenia gravis, lymphoma, immunodeficiency, asthma, and chronic respiratory failure, the facility did not administer scheduled wound treatments and dressing changes for abscesses on the right thigh and buttock on two specific dates. Although the electronic Treatment Administration Record (eTAR) was signed off as if the treatments were completed, interviews and documentation revealed that the dressings were not changed, and the wounds were not visually assessed during that period. The resident reported increased pain, which was only addressed with PRN pain medication, without further assessment or escalation to the wound care team or provider. When the wound care team finally assessed the wounds, they found significant infection and deterioration, requiring painful debridement and intravenous antibiotics, which caused additional adverse effects due to the resident's underlying conditions. Another resident, who had a pacemaker implanted and a recent generator replacement, experienced a change in the surgical site condition, including the development of scabs, erythema, and later, wound dehiscence with purulent drainage. Initial nursing assessments documented the changes and implemented standard wound care, but the wound care team was not immediately notified. The wound care nurse was only brought in several days after the initial change in condition, at which point a significant infection was identified. The resident was subsequently hospitalized for an extended period, required surgical intervention to relocate the pacemaker, and underwent extensive wound therapy. The cardiologist later confirmed that the infection was related to the resident's underlying gall bladder infection and emphasized that immediate notification should have occurred when the wound dehiscence was first noted. Facility policy required regular wound assessments, prompt documentation and intervention for pain, and immediate reporting of changes in condition, including signs of infection or wound deterioration. In both cases, the facility failed to follow these protocols, resulting in delayed interventions, progression of infections, and significant harm to the residents. Documentation showed that scheduled treatments were not completed as ordered, changes in condition were not promptly escalated, and communication with providers and specialized teams was not timely.