Failure to Monitor and Assess Post-Surgical Wound Leading to Infection and Dehiscence
Penalty
Summary
The facility failed to provide care in accordance with professional standards and the resident's person-centered care plan for a resident admitted with a left hip surgical incision following hemiarthroplasty. Upon admission, the resident's care plan required monitoring for signs of infection and skin breakdown at the surgical site, but documentation and interviews revealed that staff did not consistently assess or document the condition of the wound. The Treatment Administration Record (TAR) lacked evidence of daily monitoring for infection, and weekly wound measurements and assessments were not performed as required by facility policy. Additionally, the baseline care plan was not developed in a timely manner, and interventions for monitoring infection were not implemented or documented. The resident experienced multiple episodes of significant pain at the surgical site, which were recorded in the Medication Administration Record (MAR), but the location, quality, and aggravating factors of the pain were not assessed or documented by licensed nurses. Despite repeated reports of pain, there was no indication that the surgical wound was evaluated for changes in condition or signs of infection during these episodes. Both the physician and physician assistant did not assess the wound directly, relying instead on nursing staff, who only observed the dressing and not the underlying incision. This lack of direct assessment contributed to a failure to identify early signs of infection or wound complications. The resident's follow-up appointment with the surgeon was not scheduled in a timely manner as ordered, and the wound was not evaluated by a wound care specialist until after dehiscence occurred. When the resident eventually developed wound dehiscence with drainage and increased pain, the issue was not promptly addressed by staff, leading the resident to call emergency services independently. Subsequent hospital evaluation confirmed infection and required surgical intervention. Interviews with staff and review of facility policies confirmed that required assessments, documentation, and communication regarding the resident's wound status were not performed as outlined in the care plan and facility protocols.