F0684

G

Failure to Transcribe Aftercare Orders and Manage Surgical Wound Led to Dehiscence

Wells, Minnesota Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to comprehensively assess, monitor, care plan, and follow physician and hospital aftercare orders for a resident with a recent abdominoperineal resection and perineal surgical wound. The resident was admitted after major colorectal surgery with hospital after-visit instructions that included strict offloading of the surgical area, limits on sitting time, use of a pillow, frequent position changes, and avoidance of hard surfaces and shearing. These aftercare instructions were not transcribed into the facility’s physician orders from admission through at least 1/13, and the baseline care plan dated shortly after admission did not identify any skin integrity issues or the rectal/perineal incision. The admission MDS documented a recent GI surgery and a surgical wound, but the corresponding CAA did not trigger skin issues, and there was no baseline or comprehensive care plan addressing the surgical wound or GI surgery-related nursing care until 1/14, 12 days after admission.

During the period from admission through 1/13, the record lacked comprehensive skin assessments and monitoring of the rectal surgical incision, despite the resident having a recent major surgery requiring active skilled nursing. Staff later reported that on admission the incision was closed with sutures and without dehiscence, but there was no ongoing documented assessment. On 1/14, concern for purulent drainage from the surgical site was documented, and a skin integrity care plan and physician orders were initiated to limit sitting and promote offloading; however, prior to that date there was no documentation that offloading had been offered or attempted, and no documentation of refusals. The facility’s own appointment communication form later acknowledged that the resident had not been offloaded as ordered and had been sitting more than 10 minutes per hour without appropriate pillow or cushion use. Nursing staff also reported they were unaware of the surgical incision and offloading requirements until after the wound began to open, and there was no documentation of resident refusals or re-approach efforts.

Once the wound began to dehisce, the facility did not consistently obtain or follow complete wound treatment orders, nor did it document thorough wound assessments or timely care plan revisions in response to changes. A skin assessment on 1/15 identified a partially dehisced surgical wound with drainage and a dressing in place, but there were no corresponding wound treatment orders specifying the dressing type or duration at that time. After the surgeon ordered daily packing with iodoform or gauze and later increased packing frequency and volume, facility documentation showed use of Vashe cleanser without a physician order, incomplete descriptions of the amount of packing used, and failure to document or analyze increased drainage, odor, and wound deterioration. Progress notes described heavy, odorous drainage and changes in wound size and depth, including development of undermining and tunneling, but there was no documented comprehensive assessment of these changes, no timely notification of the surgical team when directed, and no evidence that the care plan was revised in response. Observations on 1/30 showed the wound not fully packed to the brim, saturated dressings, and mechanical debridement performed without rinsing, while the resident reported significant pain and prolonged sitting earlier in the stay. The colorectal surgeon stated that aftercare instructions were not followed, the wound was not packed correctly, there was no communication from the facility, and questioned whether facility nurses were properly trained in wound packing, while the DON acknowledged missing the hospital aftercare orders at admission and failing to ensure admission and weekly wound assessments were completed as required.

The facility’s documentation between the initial partial dehiscence and later complete dehiscence did not clearly identify when the wound fully opened or when significant changes in size occurred. Although the TAR showed dressing changes as completed per order, narrative notes revealed use of non-ordered cleansing solutions and incomplete packing. The resident reported not being instructed to limit sitting time until after the first surgical follow-up and described routinely sitting for extended periods early in the stay. Staff interviews confirmed lack of awareness of the surgical wound and offloading needs, lack of re-approach or education when repositioning was reportedly refused, and absence of refusal documentation. The DON further stated there was no documentation of monitoring that fully addressed changes to the wound between assessments since admission, despite a facility policy requiring wound treatments to follow physician orders, obtain orders when absent, and monitor effectiveness through ongoing assessment and modification when wounds fail to progress or characteristics change.

These combined failures—omission of hospital aftercare orders from admission, lack of early and ongoing comprehensive wound assessment and monitoring, delayed and incomplete care planning for the surgical wound, failure to consistently follow and clarify physician and surgical wound care orders, use of non-ordered wound cleansers, inadequate documentation of wound changes and resident refusals, and lack of timely communication with the surgical team—resulted in documented deterioration of the resident’s surgical wound from partial to complete dehiscence, with increased depth, tunneling, heavy drainage, strong odor, and increased pain requiring ongoing treatment.