Failure to Accurately Assess and Document Surgical Wounds on Admission and Weekly
Penalty
Summary
The facility failed to thoroughly and accurately assess and document a resident's surgical wounds upon admission and then weekly, as required by facility policy. Specifically, the admission skin assessment did not include all wounds present, omitting the wound on the resident's left thumb and failing to provide a description of the wound on the left hand. Additionally, there was no admission note documented in the progress notes, and the care plan in use at the time of the survey did not reflect the wounds on the resident's left hand. The wound was not included in the facility's wound report for two consecutive weeks, and there was no wound documentation in the medical record until several weeks after admission. The resident involved had multiple diagnoses, including an open wound of the left hand, cellulitis of the left finger, abscess of the left hand, and diabetes, and required surgical wound care. Interviews with staff confirmed that wound assessments and documentation were expected to be completed on admission and weekly thereafter, including details such as location, size, drainage, odor, and surrounding tissue. However, these assessments and documentation were not completed as required, resulting in incomplete and delayed wound tracking for the resident.