Failure to Assess and Monitor Wound Leading to Deterioration
Penalty
Summary
The facility failed to ensure that a wound was fully assessed on admission and monitored weekly as ordered for a resident admitted with a lower leg wound. Upon admission, the nursing documentation noted the presence of a skin tear and an open wound, but did not include specific details such as the location, measurements, appearance, drainage, odor, dressing type, or pain assessment. The facility's policy required a comprehensive skin evaluation and weekly wound documentation, including measurements and progress, but these were not completed as required. There was a gap of ten days after admission before the first wound measurement was documented, and subsequent weekly wound evaluations were inconsistent, with missing daily skilled notes and measurements. The resident, who was cognitively impaired and required assistance with activities of daily living, was admitted for skilled nursing care and wound healing. Over the course of their stay, wound documentation indicated the presence of necrosis, slough, and eventually exposed tendon, with purulent drainage and odor developing over time. Despite these changes, documentation of wound progression and communication with providers was inconsistent. Staff interviews revealed that wound care training was informal, and the wound nurse learned procedures from the previous nurse and external wound clinic staff. The DON acknowledged that wound measurements and daily skilled notes were not consistently completed, and that wound assessments were not always accurate or thorough. Concerns about the resident's wound were raised by the care team, the resident's representative, and staff, particularly when the wound developed an odor and exposed tendon. Despite these concerns, there was a delay in escalating care and obtaining appropriate provider evaluation. Eventually, the resident was sent to the hospital, where they were diagnosed with necrotizing fasciitis and required emergent surgical debridement. The lack of timely and thorough wound assessment, documentation, and monitoring contributed to the deterioration of the resident's condition.