Failure to Develop Baseline Care Plan for Post-Amputation Wound Care
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for one of three residents reviewed for baseline care plans. The resident was admitted with diagnoses including encounter for orthopedic aftercare following surgical amputation and peripheral vascular disease. Physician orders dated 08/30/25 directed specific wound care for the resident’s left below-knee amputation, including cleansing with normal saline or wound cleanser, patting dry with gauze, applying skin prep around wound edges, applying Bacitracin to the wound bed, applying Xeroform, covering with an ABD pad, and wrapping with Kerlix and an Ace bandage. Record review of the resident’s care plan, initiated on 08/30/25, showed that it did not contain any plan addressing the resident’s below-knee amputation surgical site wound care, despite the existing physician orders. During an interview on 11/21/25, the Regional Clinical Nurse confirmed that the resident’s care plan did not include a plan for the surgical site wound care. This omission constituted the failure to develop the minimum healthcare information necessary to properly care for the resident immediately upon admission.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.