F0684

D

Failure to Initiate and Coordinate Wound Care and Specialist Follow-Up for New Admission

Syracuse, New York Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for a resident admitted with significant wounds. The resident had diagnoses including gangrene of the right leg and peripheral vascular disease, and the hospital discharge summary documented gangrenous changes to the right foot, possible osteomyelitis, and a plan for follow-up at a wound clinic for hyperbaric oxygen therapy. The hospital discharge summary also included specific wound care orders for the right foot, including daily iodine skin prep, dry dressing, keeping the area dry, preventing secondary soft tissue infection, and offloading in a specialized shoe. On admission, the RN assessment noted a warm, swollen right fourth and fifth toe with a betadine dressing that was clean, dry, and intact, but did not document the type and characteristics of the wound, and there was no evidence that wound care orders for the right foot were entered upon admission.

The facility’s own policies required that on admission a licensed nurse complete a skin assessment, obtain and implement wound treatment orders, and notify a wound consultant so the resident could be added to the wound roster and seen weekly. The Wound Care and Wound Rounds Protocol required a complete skin assessment with documentation of size, appearance, and stage, physician notification, and obtaining treatment orders for any open areas. Despite these requirements, the resident’s comprehensive care plan initially only identified risk for skin breakdown and later documented a wound infection and actual skin breakdown, but there were still no wound treatment orders in place for 27 days after admission. The wound care team was not triggered to see the resident because no wound orders had been entered, and the first documented wound care provider evaluation did not occur until nearly four weeks after admission, when a nurse practitioner noted pre-existing ulcers of the right toes and heel and that the resident would have benefited from hyperbaric oxygen therapy.

Interviews with staff revealed confusion and conflicting understandings about responsibility for placing admission wound orders and the handling of an outside wound clinic appointment. The ADON and DON stated that wound care orders should be placed on admission or within 48 hours using hospital discharge or after-visit summaries, and that if orders were missing, the provider should be called. They also stated that residents were not required to see the facility wound provider before attending specialized wound appointments. However, the RN who completed the admission assessment stated they were not taught how to place orders and believed the unit manager was responsible, while the RN unit manager stated that the admitting RN was responsible for placing wound orders and that they did not check orders during the resident’s stay. Progress notes documented that the resident’s family had arranged a specialized wound clinic appointment recommended by the hospital, but the CNO directed staff not to allow the resident to leave and to cancel the appointment until the in-house wound care team evaluated the resident. The DON later confirmed that the CNO ordered the cancellation because the facility did not want to incur the cost unless the facility wound care team deemed it necessary. As a result, the resident had no wound care orders and no timely wound specialist assessment for 27 days after admission, despite documented wounds and hospital orders.