Failure to Monitor and Care Plan for Resident’s Neck Wounds After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing monitoring, assessment, and care planning after a documented change in condition for a resident with neck cancer lesions. The resident, cognitively intact and diagnosed with malignant neoplasm of the tongue and a tracheostomy, experienced increased drainage and odor from neck tumors on a specified date, as documented on a Change of Condition/INTERACT Assessment Form. The form recommended transfer to the ER to rule out infection. A progress note recorded that the physician was notified, the resident refused hospital evaluation, and staff were to continue monitoring and increase the frequency of wound treatment every shift. Subsequent documentation showed that the resident’s daughter later brought the resident to the ER for neck swelling and drainage, and that wound treatment was administered at the hospital to the lateral neck areas, with a request that the treatment nurse address the wounds in the morning. Physician orders included specific wound care regimens for the anterior neck cancer lesion and, later, for right lateral posterior and right medial posterior neck cancer lesions, with cleansing using hibiclens and application of oil emulsion dressings and ABD pads at prescribed frequencies. A skilled evaluation note indicated that a skin issue on the anterior neck had not been evaluated. Despite these orders and the identified change in condition, there was no documented evidence of the status or condition of the anterior, medial, or lateral neck wounds after the change in condition on the specified date. Interviews and record reviews further confirmed the lack of required monitoring and care planning. A LVN reported that wound care to the neck was performed daily due to increased drainage, with dressings 50–100% saturated, but this level of drainage and related assessments were not documented as required. An RN stated that the anterior, medial, and lateral neck wounds were odorous before the resident left for an oncology appointment and remained odorous upon return from the ER, and that the ER nurse had advised monitoring and treatment as needed. Both RNs and the DON stated that after a change of condition, staff should document progress notes every shift for 72 hours and update care plans, but the 72-hour monitoring process was not followed, and there was no updated care plan addressing the increased drainage, odor, or risk for infection, contrary to facility policies on change in condition, wound documentation, provision of quality care, and skin assessment.
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