F0684

E

Failure to Obtain Wound Care Orders for Abdominal Abscess

Corpus Christi, Texas Survey Completed on 02-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and implement wound care treatment orders for a resident’s abdominal wound in accordance with professional standards of practice and the resident’s person-centered care plan. The resident, an older female admitted with a cutaneous abscess of the abdominal wall and coded as being at risk for developing pressure ulcers, had a care plan initiated that identified an actual impairment to skin integrity of the abdomen related to the abscess. The care plan included monitoring and documenting the location, size, and treatment of the skin injury and reporting abnormalities or failure to heal to the physician. On admission, an LVN completed a head-to-toe assessment and documented the abdominal wound, including measurements, but did not obtain wound care orders to evaluate and treat the wound from the time of admission.

Record review showed that the resident’s abdominal wound was present and measured on admission and again on a later skin assessment, with measurements indicating the wound was resolving and decreasing in size. However, there were no wound care orders in place for several days following admission, despite the facility’s wound care policy requiring verification of a physician’s order for wound care procedures and the change in condition policy requiring physician notification for discovery of injury of unknown source or significant changes requiring alteration of medical treatment. During interview, the LVN acknowledged forgetting to place wound care orders after identifying and documenting the abdominal wound on admission, and the DON confirmed that wound care orders should have been obtained at that time. The report states that this failure could place residents at risk for wound care complications or at risk of not receiving necessary wound care.