F0684

D

Failure to Monitor and Properly Treat Trauma Wound and Supportive Leg Dressings

Boynton Beach, Florida Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor and implement appropriate treatment and obtain timely physician-directed services for a resident’s trauma wound. The resident, who had severe cognitive impairment and required substantial to maximum assistance with activities of daily living, was care planned for potential skin integrity impairment related to incontinence and cognition, with interventions to monitor and document skin injuries and report abnormalities and failure to heal to the physician. The resident was also care planned for an alteration in musculoskeletal status due to a right inner malleolus fracture, with interventions to use supportive devices such as a cast and to monitor circulation, motor function, and sensation, and later care planned for a right thigh wound with instructions to monitor and document the wound’s location, size, and treatment.

Record review showed that on one date the resident was observed pulling an ace wrap from the right lower leg up toward the knees, causing wide discoloration to the upper knees; the resident was on Plavix and considered high risk for discoloration, and the ace wrap was changed to Kerlex. A subsequent progress note documented a traumatic circular ulcer on the right leg that occurred when the resident tightened gauze supporting the soft cast, with Mupirocin ointment applied and instructions to monitor the dressing and have wound care evaluate and treat. However, there was no evidence that the cast, ace wrap, or Kerlex wrap were being monitored, no physician order for Mupirocin was found, and the only documented dressing change for the right thigh wound occurred once, with no documentation of ongoing monitoring, wound size, location, or treatment. The DON acknowledged these findings during interview.