Failure to Provide Wound Vac Care and Monitoring per Policy
Penalty
Summary
A resident admitted for rehabilitation following a left hip replacement was identified as high risk for post-operative infection and required the use of a wound vacuum (wound vac) for surgical site management. Despite this, the facility failed to develop a care plan or obtain physician orders for the wound vac upon the resident's return from the hospital, and there was no evidence of monitoring the wound vac in accordance with facility policy. The wound vac was not included in the resident's care plan or monitored as required, and physician orders lacked necessary details such as pressure settings. The wound vac was only documented as administered for three days, and when the device became full and supplies were unavailable, it was removed and replaced with wet-to-dry dressings without appropriate orders or frequency of dressing changes. Staff interviews and record reviews revealed that nursing staff were unfamiliar with the wound vac type and lacked training or competencies to provide appropriate care. The facility did not ensure that staff were educated or competent in wound vac management, as confirmed by the review of employee education files for all licensed nursing staff who cared for the resident. Additionally, after the wound vac was removed due to lack of supplies, the resident did not receive the ordered frequency of dressing changes, and the care plan was not updated to reflect the new wound care needs. As a result of these failures, the resident developed an infection at the surgical site, which required hospitalization and two subsequent surgical interventions, including a hip revision. The lack of timely care planning, physician orders, monitoring, and staff competency directly contributed to the resident's adverse outcome. The deficiencies persisted until the care plan and physician orders were finally updated more than three weeks after the initial placement of the wound vac.