Failure to Assess, Document, and Treat a New Elbow Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate treatment and care for a resident’s right elbow wound. The resident was admitted on an unspecified date, and on 01/05/26 was observed near the nurses’ station with blood on the right elbow. An LPN cleansed the elbow and applied a bandage, stating the resident had scraped the elbow on the wheel of his wheelchair. However, there was no documentation in the medical record that the resident had a wound on the right elbow, that a dressing had been placed, or that any wound assessment had been completed. On 01/08/26, the resident was observed in the hallway with a dressing that was falling off the right elbow and appeared to have dried blood. The resident stated staff had not changed the bandage since the wound occurred on 01/05/26. The wound care nurse reported she was not aware the resident had a right elbow wound until that observation and confirmed the presence of the wound and deteriorating dressing. She stated that when a new wound is identified, staff are expected to assess the wound, notify the provider and family, document the wound and notifications in the medical record, and enter wound care orders. She confirmed there was no documentation of the wound, no evidence the provider was notified, and no wound care orders in the record. The DON similarly confirmed that staff are expected to evaluate and clean new wounds, notify the provider and family, and enter wound care orders, and acknowledged that staff did not document the wound, notify the provider or family, or enter any wound care orders for this resident’s right elbow wound.
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