Neglect of Surgical Wound Care Leading to Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care to a resident’s left ankle surgical wound, resulting in neglect and an infected surgical site. The resident was admitted with an orthopedic aftercare diagnosis for a left fibula fracture and had a care plan identifying risk for skin breakdown and an actual left ankle surgical wound, with interventions including providing wound care as ordered. The resident was also care planned as being at risk for MDRO colonization/infection due to wounds, with enhanced barrier precautions in place. A physician order dated in December directed that the left ankle dressing be changed every three days using Xeroform, gauze, cling, and an ace bandage. On a late-January orthopedic follow-up, the surgeon documented that the wound looked "fantastic," with no open wounds, no evidence of infection, improved swelling, and well-healed incisions, and advised to continue local wound care per the facility’s wound care team. However, by mid-February, a nursing note documented a new skin issue: the left foot surgical incision was swollen and inflamed with a scant amount of purulent drainage. A skin assessment recorded measurements of a surgical wound on the left shin and reiterated that the left foot surgical incision was swollen and inflamed with scant purulent drainage. Around this time, the resident’s daughter reported concerns to the DON and Unit Manager that the dressing on the left foot surgical wound was not being changed and that treatments were not being done as ordered, and that the foot appeared swollen and inflamed. Facility documentation showed that on the date of the daughter’s complaint, the resident still had an active order for left ankle wound treatment every three days, but the dressing in place was dated from the beginning of the month. The e-TAR reflected that treatments were documented as completed on two specific dates and as refused on another, yet the nurse assigned on the two documented treatment days admitted to signing out the dressing changes without actually performing them. The nurse stated having a habit of signing treatments out with the intention to complete them later but becoming busy and failing to return, and confirmed this occurred on both dates in question. The resident reported that it had been a while since the last dressing change and believed the last one had been done by a male nurse on a weekend. The attending physician later assessed the wound and started the resident on Cephalexin for signs and symptoms of wound infection, and the facility’s infection control log recorded a facility-acquired left foot wound infection with onset in mid-February. The DON confirmed that the allegation of neglect related to failure to provide wound treatment per physician orders was substantiated and that the resident sustained a wound infection of the left foot.
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