F0684

G

Failure to Assess and Monitor Finger Wound Leading to Abscess and Osteomyelitis

Reedsburg, Wisconsin Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide wound care and monitoring in accordance with professional standards of practice and its own wound policy for a resident with severe cognitive impairment and multiple comorbidities. On 12/10/25, staff observed and documented an open area on the resident’s left fifth digit, noting only that the left hand pinky had an open area reported to the supervisor. No initial comprehensive wound assessment was completed at that time, and there was no documentation of wound measurements, size, or characteristics as required by the nursing process and by wound assessment best practices. The facility’s care plan identified the resident as at risk for impaired tissue integrity and directed nurses to inspect skin and assess skin status, but the documentation for this new wound remained limited to brief notes that treatment was done per order.

On 12/11/25, the physician ordered cleansing of a scab on the left pinky with soap and water and application of betadine, to be left open to air. Over the following days, progress notes repeatedly documented that wound treatment was done per order or that there was “wound care to left pinky as ordered,” without any detailed wound assessments, measurements, or descriptions of wound bed, edges, exudate, peri-wound skin, or pain. A weekly skin assessment on 12/15/25 described the skin as within normal limits with a small wound to the left pinky being treated, but again did not include a thorough wound assessment. Later on 12/15/25, staff documented that the left pinky nail appeared to be falling off with no signs or symptoms of infection, but there was no documented comprehensive assessment of this change and no physician notification recorded in the resident’s record.

From 12/10/25 through 12/19/25, there is no documentation of systematic wound assessments to indicate that staff were monitoring the wound for decline or improvement. On 12/19/25, staff noted a change in the wound appearance and reported that the left pinky was cleaned as ordered and the charge nurse was notified. Later that day, documentation described a large hematoma on the lateral aspect of the left pinky, red and warm, and the POA and on-call physician were contacted, resulting in transfer to the emergency department. In the ED, the left pinky was found to be quite swollen with purplish discoloration and purulent drainage, and the resident was diagnosed with an abscess and a possible nondisplaced fracture of the distal phalanx. Subsequent evaluations, including review of radiographs and consultation, identified erosive bone loss of the fifth distal phalanx consistent with osteomyelitis, and the NP stated that bacteria likely entered through the open area. The surveyor found no incident report, no weekly wound assessment documentation, and no evidence of wound monitoring or assessment between the initial finding of the open area and the development of the hematoma and abscess, and facility leadership acknowledged that wound assessments were not completed for what they characterized as a blood blister or hematoma.