Delayed Wound Assessment and Failure to Implement Post-Fall Treatment Orders
Penalty
Summary
A resident with multiple diagnoses, including dementia, seizures, hypertension, muscle weakness, and diabetes, developed an open area on the coccyx that was first identified by nursing staff on 8/22/25. Despite documentation of the wound on several occasions, the resident was not evaluated or assessed by the facility's Wound Nurse Practitioner until 9/12/25, approximately three weeks after the initial identification. Both the assigned nurse and the Director of Nursing (DON) confirmed that the Wound Nurse Practitioner visits weekly and should have assessed the resident at the next scheduled visit, but this did not occur. Additionally, the same resident was assessed as high risk for falls and experienced a fall resulting in a left clavicle fracture. Following the fall, the resident was transferred to the hospital emergency department (ED), where discharge instructions included the use of a sling, maintaining non-weightbearing status on the left arm, and daily monitoring of the skin around the sling. Upon return to the facility, there was no documentation in the medical record, treatment administration record, or nursing progress notes to indicate that these orders were implemented or that the resident's left arm was monitored as directed. Interviews with nursing staff revealed a lack of awareness regarding the resident's fall, fracture, and the specific post-hospital care instructions. The DON stated that it was expected for staff to implement and document hospital discharge orders, including the use of a sling and monitoring of the affected arm, but this was not done for the resident in question.