F0684

E

Failure to Complete Weekly Wound Assessments and Implement Wound Clinic Referral Orders

Los Alamos, New Mexico Survey Completed on 12-19-2025

Penalty

Fine: $47,075

Summary

The deficiency involves the facility’s failure to provide treatment and care according to physician orders and required monitoring for a resident with a left lower leg wound. Record review of the wound report from early June through early September showed multiple gaps where no weekly skin assessment documentation, including wound description and measurements, was completed. Specifically, no weekly skin assessment was found for several date ranges, and the Director of Nursing later confirmed that four weekly skin assessments were missed. When assessments were documented, the wound was identified as a skin tear on the left lower leg front with specific length, width, and depth measurements, but these were not recorded consistently on a weekly basis as expected.

The facility also failed to follow physician orders to refer the resident to a hospital wound care clinic for the front left lower extremity wound. A physician order dated late July directed a one-time referral to the wound care clinic, and subsequent progress notes documented that a nurse practitioner and the medical director each made referrals to the same wound clinic in August. However, the medical records/scheduler staff member reported never receiving any referral for this resident and confirmed that the resident was not seen at the wound care clinic. The DON stated that nurses are expected to provide copies of referrals and appointments to medical records, and the medical records staff explained that she processes referrals within hours once she receives the necessary documents. Progress notes from July through October did not show that any wound clinic appointment was made or attended, indicating that the referral orders were not carried out.