F0684

G

Failure to Assess and Provide Ongoing Treatment for Ankle Wound Leading to Severe Infection and Amputation

Lapeer, Michigan Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess, monitor, and provide ordered wound treatment to a resident’s left ankle wound. The resident was admitted with multiple serious conditions, including acute osteomyelitis of the left ankle and foot, a non‑pressure chronic ulcer of the left lower leg, diabetes with neuropathy, and a prior right below‑knee amputation. On 1/20, the practitioner assessed a swollen left ankle, anesthetized the area, lanced it, and drained approximately 60 cc of serosanguinous fluid. An X‑ray was ordered, the resident was made non‑weight bearing, an immobilizer was ordered, a culture was obtained, and the resident was noted to already be on antibiotics. The wound care assessment from that date documented an open ankle wound with instructions to cleanse with wound cleanser, apply xeroform, and cover with kerlix or border foam, with dressing changes daily and as needed.

Subsequent diagnostic results and assessments documented ongoing ankle pathology and an open wound, but nursing documentation did not reflect consistent wound care. On 1/21, an X‑ray showed deformity of the tibiotalar joint, diffuse soft tissue edema, and pockets of air collections in the soft tissues, with underlying cellulitis considered. On 1/23, a nursing progress note again described a swollen left ankle, lancing with purulent drainage, a culture (later reported as showing no organism detected), and an X‑ray indicating Charcot foot. A wound care assessment on 1/27 described Wound #2 on the left lateral ankle, acquired in‑house on 1/20, as an eroded open area at the aspiration site with white, pink‑yellow granulation tissue, fatty debris partially removed by sharp dissection, scant to moderate serous exudate, undermining from 11:00 to 3:00 up to 1.8 cm, mild subcutaneous emphysema, and apparent tendon exposure, but noted no signs of infection.

Despite these findings, the Treatment Administration Record and orders showed that a specific order for daily dressing changes to the left ankle with Medi honey, ABD pad, and kerlix was not entered until 1/27, and only one dressing change was documented on 1/28. There were no documented dressing changes or wound treatments to the left ankle between 1/20, when the ankle was first lanced and became an open wound, and 1/27, when the wound care team reassessed it. Facility assessments and progress notes did not identify or document the worsening of the ankle wound during this period. The DON acknowledged concerns with the lack of assessment, monitoring, and timely treatment orders when the skin condition worsened, and facility policies required licensed nurses to consistently monitor skin, inspect and document breaks in skin, and ensure residents with ulcers receive necessary treatment and services to promote healing and prevent infection.

A review of hospital records showed that when the resident was sent out from an orthopedic appointment to the hospital, imaging and clinical evaluation identified extensive gas in the soft tissues around the ankle, severe deformity, and findings concerning for necrotizing soft tissue infection. The ER physician documented infection on the lateral ankle with complete degeneration of the joint and purulent drainage, and the resident underwent emergent ankle disarticulation followed by a left below‑knee amputation and later a left above‑knee amputation, with postoperative diagnosis of necrotizing fasciitis of the left lower extremity.