Failure to Timely Assess and Treat Surgical Wound on Admission
Penalty
Summary
Facility staff failed to provide timely assessment and treatment of a surgical wound for one resident following admission. The resident had recently undergone a lumbar laminectomy and was admitted to the facility from the emergency room with a dressing over the laminectomy site that appeared normal and had been placed several days earlier. Emergency room discharge notes documented the recent surgery and the presence of the dressing, and the resident’s admission MDS later identified a surgical wound and surgical wound care. However, the nursing admission assessment dated 3/29/2024 documented no skin impairment, despite a subsequent skin assessment describing a surgical incision to the lower back with specific measurements, granulation tissue, scab, and moderate serous drainage, indicating the wound was present on admission. Physician orders dated 4/1/2024 directed staff to cleanse the lower back surgical wound with wound cleanser, pat dry, and apply calcium alginate and silicone foam dressing daily and as needed until healed, and the comprehensive care plan for impaired skin related to the laminectomy was also initiated on that date. There was no evidence of any wound treatment orders prior to 4/1/2024 or any order to leave the dressing intact and not remove it. Review of the eTAR for March showed no treatments completed for the surgical wound. In interviews, nursing staff and the DON stated that standard practice was to complete a full head-to-toe skin assessment on admission, identify any wounds, and obtain or confirm treatment orders from hospital discharge information or the physician, including orders to leave dressings in place if applicable. The facility’s skin assessment policy required a full body skin assessment by a licensed or registered nurse upon admission, but the resident’s surgical wound was not assessed and treated until several days after admission.
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