F0686

D

Failure to Follow Up on Wound NP Recommendation for Possible Antibiotics for Infected Pressure Wound

Canton, North Carolina Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow up on a wound care nurse practitioner’s recommendation to contact the primary care provider regarding possible antibiotic treatment for a resident’s pressure-related hip wound that showed signs of infection. The resident had severe cognitive impairment, required extensive to total assistance with all ADLs and mobility, and was identified as at risk for pressure ulcers, with existing unhealed stage 3 and unstageable pressure ulcers and a pressure-reducing device in use. A care plan directed staff to administer treatments as ordered, monitor wound healing weekly, and report improvements or declines to the MD.

On 12/31/25, Wound Care NP #2 evaluated the resident’s right hip wound, which had declined, and documented that there were positive signs and symptoms of infection, recommending that staff contact the primary care physician for possible antibiotic treatment. NP #2 ordered Santyl for debridement because the wound was covered with unstable eschar and reported that the wound was bad, with moderate purulent drainage and odor, leading her to believe there was likely infection present. She stated that her process was to notify the primary care provider and defer to them for the antibiotic decision, and she discussed with the facility’s wound care nurse that the resident had symptoms of infection and needed follow-up with the primary care provider, which she also documented in her note.

Despite this recommendation and documentation, review of the electronic medical record showed no antibiotic orders and no progress note indicating that the primary care provider had been contacted. The facility’s wound care nurse (Nurse #2) stated she was aware of NP #2’s note and said she mentioned the possible need for antibiotics to NP #1 when NP #1 was at the facility, but NP #1 allegedly did not think the resident needed an antibiotic and did not examine the wound; NP #1, however, reported she had not been informed and did not recall being contacted about the wound or need for antibiotics. On observation by the surveyor, the right hip wound had copious purulent brown drainage saturating the dressing and under-pad, a malodorous smell, a visible cavity, and remaining eschar, and was measured at 4 cm by 5 cm by 5.5 cm. The Medical Director later stated he had not been contacted about the wound or antibiotics and that someone should have followed up on the wound NP’s recommendation. The DON and Regional Nurse acknowledged that information about the possible need for antibiotics should have been communicated to the primary care provider and that outside provider notes were expected to be reviewed and addressed by the clinical team, but the DON did not recall reviewing the 12/31/25 wound note, and there was no evidence that the recommendation for possible antibiotics was acted upon prior to the surveyor’s involvement.

The deficiency therefore centers on the facility’s failure to implement and act upon the wound care NP’s documented recommendation to contact the primary care provider regarding possible antibiotic therapy for a wound with documented signs and symptoms of infection, and the lack of documented communication or follow-up with any provider despite the resident’s high-risk status, existing pressure injuries, and care plan requirements to monitor and report wound changes to the MD.