F0684

D

Failure to Complete Ordered Follow-Up Visit and Weekly Wound Assessments

Rushville, Indiana Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care according to provider orders and facility policy for a resident with multiple comorbidities. Resident C had diagnoses including COPD, heart failure, and kidney failure, and a quarterly MDS indicated cognitive impairment, need for staff assistance with hygiene, and no pressure areas at that time. A behavioral care plan revised in late September directed staff to make referrals as needed. A provider visit note in mid-November documented that the resident was having behavioral issues, with a plan that included medication changes and a follow-up visit in two to three weeks or sooner if indicated. However, during an interview, the NP reported that the resident was not seen again after that mid-November visit, and the record contained no evidence that the ordered follow-up visit occurred.

The facility also failed to complete and document weekly wound assessments as required by its Skin Management policy. The resident’s skin care plan, revised in late September, identified skin impairments and directed staff to inspect the skin every shift and report changes. A weekly wound assessment in mid-November showed a blister on the resident’s left leg, but there were no weekly wound assessments documented from the following day through late November. A subsequent weekly assessment in late November documented two venous ulcers on the left leg, followed by another gap with no weekly wound assessments from late November through early December. A weekly assessment in early December then documented two venous ulcers on the left leg and one venous ulcer on the right leg. The facility’s Skin Management policy required immediate treatment for any open area and weekly assessments with ongoing wound documentation, which were not consistently completed for this resident.