F0684

G

Failure to Timely Enter and Implement Wound Care and Antibiotic Orders for Infected Finger Injury

Clearwater, Florida Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and enter physician orders for wound care and infection treatment in a timely manner for a resident with a right fifth finger injury. The resident had multiple significant medical diagnoses, including bilateral below-knee amputations, chronic congestive heart failure, Type 2 diabetes mellitus with diabetic chronic kidney disease, muscle wasting and atrophy, altered mental status, and delusional disorder. A skin evaluation dated 10/20/2025 documented bruising and an open area on the right hand pinky, identified as a new in-house skin tear. Progress notes from that date showed the nurse observed an open area on the right pinky finger, notified the unit manager and wound care team, and documented that the resident reported his finger had become tangled in the wheelchair wheel. However, no treatment orders were documented or implemented at that time for the finger wound.

Staff interviews revealed that on 10/20/2025, an LPN observed the resident’s right pinky finger as swollen, necrotic, with pus and a blister, and stated she could tell the finger was infected and that it appeared to have been developing for a few days. She acknowledged that no treatment was provided until 10/22/2025 and that she should have immediately notified the provider but did not. On 10/21/2025, the wound care nurse and unit manager saw the resident for other wound care and noted the right pinky as swollen, discolored, with drainage and a blister, but the skin issue entry for the finger remained “not evaluated,” and there was no documentation of treatment orders being obtained or initiated that day. The DON and regional nurse consultant both stated that facility expectations were that any open area should prompt immediate provider notification, with documentation of that notification and prompt entry of any resulting orders.

Record review showed that the resident’s primary care provider saw the resident in person on 10/20/2025 and, according to an untitled document later signed by the provider, gave orders for an x-ray of the right hand, Doxycycline, and topical Bacitracin for the right fifth digit on that date. However, these orders were not entered into the facility’s system until 10/22/2025 and 10/23/2025, when an x-ray order dated 10/22/2025 and medication orders dated 10/23/2025 appeared in the physician orders. A late entry progress note dated 10/22/2025 documented a call placed to the physician regarding the infected, swollen, and bruised right pinky finger and indicated the physician would examine the resident while rounding. The regional nurse consultant and DON confirmed that orders should be added as soon as they are given and that the facility’s policy requires noting, dating, signing, and confirming the accuracy of physician orders, with daily review to identify errors of omission. The failure to promptly enter and implement the provider’s wound care and antibiotic orders resulted in the resident going without ordered infection treatment for two days before further diagnostic testing and transfer occurred.

Radiology records showed that an x-ray of the right hand, performed on 10/22/2025 and reported on 10/23/2025, demonstrated subtle bone loss at the fifth DIP joint with swelling, with a conclusion suggesting osteomyelitis and recommending an MRI. The DON stated that the primary care provider suspected osteomyelitis related to the right pinky finger and that the x-ray results revealed osteomyelitis. Hospital records documented that the resident presented for evaluation of the right small finger injury, with initial hand x-rays demonstrating signs of cellulitis and osteomyelitis, and that IV antibiotics were initiated. The resident subsequently underwent resection (amputation) of the right small finger. Throughout this sequence, the survey findings focused on the gap between the provider’s in-person assessment and orders on 10/20/2025 and the facility’s failure to timely enter and implement those orders, despite multiple staff observations and documentation of the injured, infected right pinky finger.