Failure to Provide Ordered Surgical Wound Care Resulting in Infected Abdominal Incision
Penalty
Summary
The facility failed to provide physician-ordered surgical wound care to a resident with an abdominal incision following digestive system surgery. Facility policy dated 09/15/25 required safe and effective wound care, adherence to specific orders for surgical wounds, and daily monitoring of wounds and dressings for complications or decline. The resident was admitted on 09/03/25 with diagnoses including surgical aftercare following digestive system surgery, incisional hernia without obstruction, and unspecified intestinal obstruction. Physician orders dated 12/17/25 directed that the abdominal wound be cleansed with wound cleanser, patted dry, packed with optical AG rope, and covered with a foam dressing every day shift from 12/17/25 through 12/23/25. The Treatment Administration Record for 12/17/25 through 12/23/25 showed the wound care as completed every shift as ordered. However, nursing progress notes dated 12/22/25 documented that the midline abdominal surgical wound dressing was changed that day, and that the last dressing change had actually occurred on 12/18/25, indicating that ordered wound care had not been completed between 12/18/25 and 12/22/25. At that time, increased drainage with thick brown serosanguineous fluid and increased redness around the wound were observed, and the wound nurse was notified of the worsening appearance. A communication form entry dated 12/22/25 recorded a reddened abdominal incision with purulent drainage, with the resident reporting the dressing had not been changed since 12/17/25. A wound culture subsequently tested positive for gram negative and gram positive bacteria, and the resident’s daughter was notified of the missed treatments and positive culture. In interviews, the daughter confirmed being told that the bandage had not been changed for several days, the Infection Preventionist/Unit Manager acknowledged that scheduled wound care was missed from 12/18/25 through 12/22/25 and that the incision became inflamed, reddened, and MRSA-positive, and the DON confirmed that the wound care was not completed per physician orders.
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