Failure to Provide Adequate Post-Surgical Wound Care
Penalty
Summary
The facility failed to provide adequate post-surgical wound care for one resident following spinal surgery. Upon admission, the resident had clear aftercare instructions from the hospital to clean the incision daily with mild soap and water, and to keep the area dry. Physician orders were in place to monitor the surgical site for signs of infection and to keep the incision clean and dry, with wound nurse follow-up. However, documentation revealed that these orders were not consistently followed. The treatment administration record did not show evidence that the wound was routinely kept clean and dry from admission through a significant period, and the wound nurse did not assess the incision regularly as ordered. Progress notes indicated that the resident experienced increasing redness, pain, and eventually drainage and malodor at the surgical site, with concerns for infection and dehiscence. Despite these symptoms and multiple provider consultations, there was a lack of consistent documentation of wound care and hygiene. The resident required assistance with hygiene and was only provided bed baths on a few occasions, with limited evidence of showers or proper incision cleaning as per discharge instructions. The wound nurse confirmed that the incision should have been cleaned daily and acknowledged gaps in wound assessment and care.