Failure to Document and Assess Surgical Wound per Facility Policy
Penalty
Summary
The facility failed to properly assess and document a surgical wound for a resident with multiple medical diagnoses, including a right femur fracture, chronic obstructive pulmonary disease, dementia, chronic kidney disease Stage IV, and pneumonitis. Upon admission, the resident was noted to have a surgical site on the right hip with 29 staples, but the initial assessment did not include measurements or a detailed description of the wound. Subsequent weekly skin observations also lacked documentation regarding the surgical site, its measurements, or a description of the wound. An LPN confirmed that during the resident's stay, there was no documentation of the surgical wound's measurements or description in the medical record. The facility's wound care policy required documentation of wound type, assessment data (including size and wound bed color), and other relevant information, but these requirements were not met for this resident. This deficiency was identified during a review of the medical record, staff interviews, and policy review, and was investigated under specific complaint numbers.