F0684

G

Failure to Follow Wound Physician Orders for Cultures, Imaging, and Change-in-Condition Notification

Springfield, Missouri Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow wound physician recommendations and treatment orders for a resident with a severe vascular wound to the left shin. The resident was admitted with traumatic ischemia of muscle, peripheral arterial disease, diabetes mellitus type II, deep vein thrombosis, and existing venous/arterial ulcers, and was cognitively intact but dependent on staff for most activities of daily living. The care plan identified an infected arterial wound to the left shin and directed staff to perform wound treatments per current orders, assess for signs and symptoms of infection with each dressing change, and report any positive findings or lack of response to treatment to the physician. The facility’s policy on notification of change in condition required licensed nursing staff and nursing administration to notify the attending physician or nurse practitioner of changes in a resident’s condition.

Beginning on 10/02/25, the wound physician’s report documented an infected left shin wound present on admission, with significant slough, odor, erythema, and purulent drainage, and specifically recommended obtaining a deep wound culture. Subsequent weekly wound reports dated 10/09/25, 10/16/25, and 10/23/25 continued to recommend a wound culture, and later reports on 10/30/25, 11/14/25, 11/21/25, and 11/26/25 added recommendations for an X-ray of the left shin/leg to evaluate for osteomyelitis. Despite these repeated recommendations, the resident’s medical record contained no documentation of wound culture results or X-ray results. An LPN acknowledged that an order dated 10/02/25 to obtain a wound culture appeared on the treatment administration record and that he/she documented “NA” and did not obtain the culture, stating he/she could not locate culture swabs. The DON and Administrator later confirmed they were unable to find any wound culture or X-ray results in the record and that such orders should have been carried out and documented.

As the wound progressed, multiple assessments documented worsening characteristics and ongoing infection. On 11/14/25, a different wound physician noted a larger wound with necrotic and devitalized tissue, odor of pseudomonas, and recommended referral to a vascular surgeon along with wound culture and X-ray. On 11/26/25, the wound nurse documented a full-thickness arterial wound with necrotic tissue, moderate purulent drainage, and stated that diagnostic studies including X-ray and deep wound cultures were pending, yet no results were recorded. On 11/28/25, an RN documented that the wound had declined, with more drainage, foul odor, and increased pain, and wrote that he/she would inform the physician of these changes on the following Monday rather than immediately. The next day, another nurse documented the resident was lethargic with nausea, vomiting, chills, shaking, and excessive green purulent drainage with foul smell from the left shin wound, and the resident was sent to the emergency department. Hospital records described an extensive infected left lower extremity wound with necrosis and cellulitis, and the plan included proceeding with amputation. Interviews with nursing staff and leadership confirmed that the physician was not notified of the 11/28/25 change in condition at the time it occurred and that ordered or recommended wound cultures and X-rays were not obtained or documented, leading to the cited deficiency for failure to provide treatment and care according to orders and physician recommendations.

Interviews further clarified the sequence of inactions contributing to the deficiency. The wound nurse stated that he/she routinely reviewed the wound physician’s after-visit summaries and entered new or changed orders into the electronic medical record, and that the facility had completed topical treatments as ordered, but acknowledged the leg was necrotic with pus and odor from admission and that the wound physician anticipated the need for amputation. An RN reported that on the day before the resident was sent to the hospital, the wound was covered in moist eschar with yellow-green drainage and foul odor, but he/she did not call the physician, believing the wound physician was already aware and that the situation could wait until after the weekend. Another nurse who arranged the hospital transfer relied on a colleague’s report of the wound condition and was not aware of any wound culture orders. The DON and Administrator both stated that nurses should have obtained ordered cultures within the same shift, notified providers promptly of changes in condition, and ensured that wound physician recommendations for cultures and X-rays were entered and completed, but the record and staff interviews showed this did not occur for this resident.

Overall, the deficiency centers on the facility’s failure to implement and document wound physician recommendations for deep wound cultures and diagnostic imaging over multiple weeks, and failure to promptly notify a physician or nurse practitioner when the resident’s wound and overall condition worsened. These failures occurred despite clear care plan directives to monitor and report wound changes and a facility policy requiring provider notification of changes in condition. The absence of culture and X-ray results in the medical record, the LPN’s admission that a culture was not obtained despite an order, and the RN’s decision to delay notifying the physician about significant wound decline until after the weekend collectively demonstrate the inactions and missed interventions that led to the cited deficiency for not providing appropriate treatment and care according to orders and the resident’s needs.