Failure to Perform Ordered Surgical Wound Care Resulting in Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatment in accordance with physician orders for a resident with a left fibula fracture and a left ankle surgical wound. The resident was cognitively intact and had a care plan identifying risk for skin breakdown and MDRO colonization/infection, with interventions including providing wound care as ordered and using enhanced barrier precautions. A physician order dated in December directed that the left ankle surgical wound dressing be changed every three days using Xeroform, gauze, cling, and an ace bandage. An orthopedic surgery note from late January documented that the wound looked “fantastic,” with no open wounds or evidence of infection, and instructed to continue local wound care per the facility’s wound care team. On a date in February, the resident’s daughter reported to the DON and Unit Manager that she believed the surgical wound dressing was not being changed and treatments were not being done as ordered, and that the foot appeared swollen and inflamed. A nursing note that same day documented a new skin issue: the left foot surgical incision was swollen and inflamed with scant purulent drainage. A skin assessment recorded measurements of a left shin surgical wound and again noted the left foot surgical incision as swollen and inflamed with scant purulent drainage. The following day, a nurse documented a change of condition, physician notification, initiation of Cephalexin 500 mg, and a change in the wound care order to daily dressing changes. A physician order dated that day specified daily cleansing of the left ankle surgical wound with wound cleanser, patting dry, applying Xeroform, and wrapping with Kling, and an order for Cephalexin 500 mg every six hours for seven days for a wound infection. The facility’s infection control log recorded that the resident acquired a facility-onset left foot wound infection treated with Cephalexin. The facility’s internal investigation found that on the date of the daughter’s complaint, the active order remained for dressing changes every three days, but the dressing in place was dated from the first of the month. The ETAR showed the treatment as completed on two subsequent dates and refused on another, yet the nurse assigned on those two dates admitted to signing out the dressing changes before actually performing them and then failing to return to complete the treatments. 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 DON confirmed these findings, and the deficiency was cited as past non-compliance resulting in actual harm when the resident developed a left foot surgical site wound infection due to wound treatment not being completed as ordered.
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