Failure to Perform and Document Daily Surgical Wound Dressing Changes as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care according to physician orders for a resident with a dehisced surgical wound on the right posterior ankle and a history of recurrent wound infections. Surveyors observed the resident in bed with a right ankle dressing dated 2/5/26, despite the resident’s statement that the dressing was supposed to be changed daily but was not being changed. The resident reported the wound had been infected previously and required an injection. The resident’s daughter stated that the facility’s lack of care to the ankle wound led to infection and that the wound improved during the week but worsened on weekends when dressings were not changed. The Assistant DON, who served as the wound care nurse, confirmed the wound was a dehiscence from surgery, ordered for daily dressing changes, and that she personally performed dressing changes during the week, with the last change documented on 2/5/26. Record review showed the treatment administration record ordered daily wound care to the right lower leg, including cleansing, application of medi-honey, and covering with bordered gauze once daily and PRN if saturated, soiled, or dislodged. The TAR reflected that the dressing was changed on 2/6/26, even though the physical dressing remained dated 2/5/26 and the resident stated it had not been changed. The EMR documented three wound cultures over the prior three months, with two cultures positive for gram negative bacilli and one negative culture, and the MAR showed the resident had been treated with Bactrim DS and later ceftriaxone for wound infections. The resident’s care plan identified a dehiscence of the surgical site to the posterior right lower extremity with an intervention of treatment as ordered. The facility’s skin policy required a licensed nurse to observe wound/incision condition daily or with dressing changes and document findings, with physician and responsible party notification for acute changes, but the observed and reported failure to perform and accurately document daily dressing changes demonstrated noncompliance with these requirements.
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