Failure to Assess and Care Plan Surgical Incision on Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure licensed nurses completed wound assessments and developed a care plan for a resident’s surgical incision upon admission. The resident was admitted with diagnoses including post-fall, subdural hematoma, and status post craniotomy, and the admission History and Physical documented a right temporal surgical incision present on admission. An initial body assessment on the admission date noted a new surgical wound on the right temporal area, identified as a surgical wound present on admission, but stated that measurements were not documented because the resident wanted the assessment done another day and wanted to rest. From the admission date through several subsequent days, progress notes repeatedly documented the same entry about the new surgical wound, its location, and that measurements were not taken for the same stated reason. There was no evidence in the medical record that wound measurements or a detailed description of the incision were ever completed during this period. The record also lacked a care plan addressing the surgical incision, including treatment or monitoring interventions, and there were no hand-off reports or documentation to support continuity of care among staff regarding the wound. Additionally, there was no documentation that the physician was notified about the surgical incision. In interviews, an RN described the facility’s usual process for residents with wounds, including admission assessment, notification of the treatment nurse, completion of a full assessment within 24 hours, and notification of the physician and family, and stated that nothing had changed in how wound assessments were to be done. The DON acknowledged that the resident’s medical record was missing the surgical wound assessment and confirmed there was no care plan developed for the incision, despite the facility’s care plan policy requiring individualized, comprehensive care plans for identified resident problems.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.