Failure to Timely Assess and Care Plan Venous Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and treatment and to complete a timely, comprehensive assessment and care plan for a resident’s venous wound. The resident was admitted with hepatic encephalopathy, alcohol cirrhosis with ascites, and pancreatic cancer, and the admission assessment and MDS documented no skin issues, though the resident was identified as at risk for skin concerns and required moderate assistance with bathing, dressing, and bed mobility. On 1/10/26, a nurse’s note documented new skin issues discovered after a shower, including a left elbow abrasion with skin peeling, right elbow skin peeling, right thumb skin peeling, and a left heel open blister, along with +3 pitting edema to both feet and bilateral lower extremities elevated with a pillow and pressure relief boots applied. The note also documented that all areas were cleansed with normal saline and dressed with xeroform and foam, and that the on-call NP was updated. Despite these findings, the treatment orders were not transcribed to the Treatment Administration Record, a comprehensive wound assessment with measurements and skin type was not completed, and the resident’s care plan was not revised to address the new skin issues identified on 1/10/26. The facility’s policy on skin tears, abrasions, and minor breaks required documentation of causation, completion of a non-pressure form, physician and family notification, resident education if completed, resident tolerance of procedures, complications, refusals, and preventive interventions, as well as completion of an incident/accident report when such issues were discovered. On 1/12/26, the wound MD assessed the resident and documented a venous wound to the left foot measuring 10 by 80 cm with unmeasurable depth due to dried fibrous exudate and recommended increased level of care and oral antibiotics for cellulitis. The same day, nursing notes documented that the resident was confused and not behaving normally, and the resident was sent to the hospital. The DON later acknowledged there was no comprehensive assessment until 1/12/26 and no baseline care plan related to skin integrity until 1/13/26, and stated she believed nurses were waiting for the wound MD to assess the wound.
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