**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services for one of 16 sampled residents (Resident 53) when the facility did not remove the surgical site staples per the physician's orders; the facility did not assess the surgical site per the plan of care and the facility policy and procedure; or revise the comprehensive care plan to address a change in skin integrity and infection at the surgical site. This deficient practice resulted in an infected surgical site for Resident 53. Findings: During a review of the clinical record of Resident 53, it indicated he was admitted on [DATE] for rehabilitation following a joint replacement surgery. Resident 53's medical diagnoses included a fractured right femur (broken right leg), sepsis (a life threatening infection of the blood stream), difficulty walking, and prediabetes (a condition involving high blood sugar with no other presenting clinical signs or symptoms). Resident 53 is his own responsible party. A review of the Minimum Data Set (MDS - a resident assessment tool) for Resident 53, dated 3/24/19, indicated the Skin Condition section of the MDS reflected the resident had a surgical wound upon admission. Resident 53 had a Brief Interview for Mental Status (BIMS - an aide in detecting cognitive impairment) score of 15 (meaning no cognitive impairment). During an observation and a concurrent interview with Resident 53, on 6/3/19, at 9:14 AM, in the room of Resident 53, Resident 53 sat in a chair and stated he was admitted to the facility for a broken leg, which made it difficult to move, stand up, and use the bathroom. During a concurrent record review and interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the binder of treatment records and stated, There's no wound care treatment performed to his surgical site today. The Treatment Administration Record [TAR] for Resident 53, between 6/1/19 and 6/30/19, indicated an order effective 5/31/19 through 6/4/19 to cleanse the area and pat dry the surgical site on the right distal femur, and apply a nickel sized amount of Santyl ointment (an ointment that removes dead tissue) to the right distal femur surgical site's wound bed avoiding contact with surrounding skin, apply wet gauze (dressings are used to help maintain a moist wound healing environment) to the wound or Hydrogel gauze (a dressings used for packing deep wounds and maintaining a moist wound), and cover the area with a dressing, every other day. During a concurrent record review and interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the skin assessment records in the Treatment binder for Resident 53, such as the Non Pressure Sore Skin Report[s] from admission until present (6/4/19), the TAR, dated 6/1/19 and 6/30/19, and the initial skin assessment, dated 3/17 /19. Staff 24 stated, The last time a skin assessment sheet was completed was on 5/23/19, but the skin assessments records in the binder don't address the surgical site on the right lower femur. When asked if all skin assessments for surgical sites should be documented in the ''.Treatment binder, Staff 24 stated, They [the records in the Treatment binder] should [address the surgical wound] . The skin assessment sheets [reports] should be done every week . During a concurrent observation and interview with Resident 53, on 6/4/19, at 10:43 AM, in the room of Resident 53, a clean and dry dressing covered his right femur. Resident 53 declined an observation of his wound care for the surgical incision on the next day. A review of the Skin Assessment Record for Resident 53, dated 3/17/19, indicated 22 staples on the surgical site. There was no other documentation on the characteristics (such as redness and measurements) of the right femur surgical site or the signs or symptoms of infection present. A review of the Progress Notes for Resident 53, between 3/17/19 and 3/24/19, indicated a dressing covered the surgical incision site upon admission. No documentation of a physician or orthopedist (a medical specialty which focused on the skeletal system) notification on the staple removal from the surgical site 3/17/19 through 3/24/19. The notes indicated no documentation of an assessment or treatment performed to the surgical site between 3/18/19 and 3/24/19. A review of a Nursing Weekly Assessment for Resident 53, dated 3/24/19, indicated a description of surgical wound with 22 staples in the Skin Assessment section. A review of the Comprehensive Care Plan of Resident 53 included care plans to address the skin integrity of the surgical site and potential for infection related to the surgical site. The care plan for Resident 53 titled: .Altered Skin Integrity r/t [related to] Surgical Wound . with 22 staples . revised 3/24/19, indicated goal and interventions, such as assessing the site for signs and symptoms of infection (redness, swelling, pain, and drainage, the liquid produced by the body in response to tissue damage), to identify and prevent wound complications, such as infection. Another care plan for Resident 53 titled: .Potential for infection . surgical wound site, revised 3/17/19, indicated measures to address the risk for infection. A review of a Physician's Order for Resident 53, dated 3/25/19, indicated the physician ordered laboratory testing in one week (4/1/19). A review of the Progress Notes for Resident 53, dated 3/25/19, indicated the physician ordered a complete blood count [laboratory testing to evaluate the composition of the blood] for 4/1/19 without a documented reasoning for ordering the test. There was no documentation of a notification or communication to the physician or the orthopedic surgeon regarding the surgical staple removal. A review of the Progress Notes for Resident 53, dated 3/26/19, indicated, . at 10:30 [am] 22 staples were removed from his right thigh, applied skin closure strips and island dressing [a dressing used to absorb fluid from wounds, such as surgical sites] . A review of the Progress Notes for Resident 53, dated 3/27/19, indicated the nurse called the physician regarding surgical site drainage and redness noted at 16:01 PM. A note at 22:09 PM indicated no frequency of the New order to cleanse surgical incision on right thigh with . apply triple atb [antibiotic medication used against bacterial infections] ointment and cover with island dressing. A review of the TAR for Resident 53, between 3/1/19 and 3/31/19, indicated three orders unrelated to any treatments, e.g. the order for the removal of the surgical staples, or assessments or monitoring of the site. A review of the Laboratory Result Report for Resident 53, received 4/1/19, indicated a WBC (white blood cell - cells in the immune system involved in fighting infection) level of 9.3, higher than the Reference Range of 4.2 9.1 K/uL (cubic milliliter). According to Medline Plus, 2019, infection is a cause of a high white blood cell count. [https://medlineplus.gov/ency/article/003657.htm]. A review of a Progress Note for Resident 53, dated 4/2/19, indicated the nurse notified the physician of serosanginous/yellow [a combination of both blood and serous fluid] drainage noted on old dressing . The note also indicated, Resident denied pain, but [reported] tenderness. Warm to touch, right leg brace kept on. Received [a physician's] order to start Keflex [a medication used against bacterial infections] . Order carried out. A review of the Medication Administration Record [MAR] for Resident 53, between 4/1/19 and 4/30/19, indicated an order to give one capsule (containing 250 milligrams) of Keflex by mouth four times a day for a wound infection, from 4/2/19 until 4/9/19; order for Keflex repeated from 4/10/19 until 4/12/19. A review of the TAR for Resident 53, between 4/1/19 and 4/30/19, indicated three orders, none of which addressed an assessment or wound care orders for the surgical site. A review of the Physician's Progress Note for Resident 53, dated 4/3/19, indicated the right femur fracture had redness and slough [yellow or white colored dead skin tissue] on the incision site and an order to .add Santyl to the area of slough on 4/3/19. A review of the Nursing Weekly Assessment for Resident 53, dated 4/ 4/19, indicated one surgical site listed on the right trochanter [upper portion of the leg] had a description of a Surgical Wound with 22 staples. There was no documentation of a surgical site on the right distal femur included. A review of the Physician's Progress Note for Resident 53, dated 4/8/19, indicated the Santyl [was] not working well; will refer to orthopedic surgeon for debridement [a procedure that removes dead tissues]. Continue on Keflex . A review of the Physician's Order for Resident 53, dated 4/8/19, indicated an order to Refer back to orthopedic surgeon to debride wound at incision. During a concurrent record review and interview with Staff 3, on 6/5/19, at 10:09 AM, Staff 3 was asked to detail the skin assessments process and documentation. Staff 3 stated the nurses were trained to conduct skin assessments of a surgical site on admission and document a skin assessment in the Treatment binder once a week. When asked to describe the documentation for a skin assessment, Staff 3 answered, Nurses must document the wound's size, drainage, wound bed appearance, odor . Staff 3 reviewed the clinical record of Resident 53 and stated Resident 53 had a surgical site on the right distal femur. Staff 3 further reviewed the resident's records in the Treatment binder, the TARs, the Physician's Orders, the Non Pressure Sore Skin Report[s] recorded from admission until present (6/4/19), the Progress Notes, between 3/17/19 and 6/4/19, and acknowledged wound infection and orders for Keflex, wound care, and wound debridement began in the facility and were not present on admission. In addition, Staff 3 acknowledged there was no documentation of a skin assessment between 3/18/19 and 3/25/19. When asked if the Nursing Weekly Assessments incorporate a skin assessment of the surgical site, she stated, No due to the lack of information, such as the wound's measurements and drainage, in all the records (including 3/24/19 and 4/4/19). Staff 3 further stated, .The first assessment isn't even right, the surgical site is on the right lower leg, not the trochanter . Staff 3 also acknowledged the Progress Notes did not contain documentation of an assessment or treatment of the right distal femur surgical site between 3/18/19 and 3/25/19. Staff 3 reviewed the comprehensive care plan and stated the care plan on the skin integrity of the surgical site [on the right femur] and the potential for infection needs to be revised as no update occurred since March 24th [2019] [prior to the surgical staple removal and the surgical site infection]. During a concurrent record review and interview with Staff 20, on 6/5/19, at 3:11 PM, Staff 20 stated Resident 53 was admitted to the facility with a surgical wound. Staff 20 reviewed the Inter Facility Transfer Report (the general acute care hospital [GACH] discharge summary) for Resident 53, dated 3/17/19, and the clinical record of Resident 53. Staff 20 stated Resident 53 received discharged orders from the GACH's physician to remove the surgical staples on the right femur on 3/24/19. Staff 20 stated the progress notes did not document a skin assessment or treatment performed to the surgical site on the right femur between 3/18/19 and 3/25/19, and a Progress Note for Resident 53, on 3/26/19, was the first documentation covering the removal of the right femur's surgical staples. Staff 20 reviewed the Progress Notes, between 3/17 /19 and 3/25/19, and was unable to find documentation of a notification to the physician or orthopedist regarding the removal of the right femur's surgical site staples, or any documentation to remove the surgical site staples on different date than 3/24/19, ordered by the GACH physician. Staff 20 stated the surgical staples were removed late, and the resident's surgical site became infected, which required antibiotics, wound care treatments, and wound care debridement. Staff 20 acknowledged the Progress Notes for Resident 53, between 3/17/19 and 3/25/19, indicated no documentation of an assessment or treatment performed to the surgical site on the right femur between 3/18/19 and 3/25/19 or a notification to a physician or orthopedist (a medical specialty which focused on the skeletal system) regarding the removal of the surgical staples on the right femur's surgical site between 3/17 /19 through 3/25/19. Staff 20 reviewed the Initial Assessment, dated 3/17/19, and the Weekly Nursing Assessment, dated 3/24/19 and 4/4/19, and stated the records lacked the assessment information, such as the characteristics of the surgical site. When Staff 20 was asked to provide additional skin assessment of the surgical site on the right femur, Staff 20 was unable to provide additional documentation. Staff 20 acknowledged revision dates for the care plans on the potential for infection and the surgical wound's skin condition, were outdated and required revision. During a concurrent record review and interview with Staff 12, on 6/6/19, at 3:14 PM, Staff 12 was asked about performing and documenting skin assessments. Staff 12 replied, Skin assessments for surgical wounds are documented once a week in the Treatment binder . An assessment for a surgical wound includes noting the redness, appearance of the dressing . a wound infection assessment consists of documenting the amount and appearance of the drainage, the smell of the wound, the drainage, the temperature of the resident . Staff 12 was asked when care plans on wounds and infection were revised. Staff 12 answered, .The care plans are revised when there is a change in the wound or when there is a new infection present . Staff 12 reviewed the skin assessment records for Resident 53 in the Treatment binder and was unable to provide documentation of a surgical wound assessment. After reviewing the clinical record of Resident 53, Staff 12 acknowledged the surgical staples removal was late and the skin assessments records on the surgical wound's condition didn't have enough entries or details. In addition, upon further review of the care plan, Staff 12 stated the care plan addressing the skin integrity of the surgical site, revised 3/24/19, indicated the care plan still shows when the resident has surgical staples, and the care plan on the potential for infection is overdue for a revision. Staff 12 added both care plans had interventions and goals created no more than two weeks after he came here [was admitted to the facility]. Staff 12 added the comprehensive care plan needs to be revised as the resident was no longer at risk for infection, but had a diagnosis of infection at surgical site. Staff 12 acknowledged without the necessary care (the lack of skin assessments, late surgical staple removal and care plan revisions) the surgical site became infected, which required Keflex, wound care treatment, and debridement. During a record review and interview with Staff 2, on 6/7/19, at 12:12 PM, Staff 2 was asked about the skin assessment process. Staff 2 answered nurses assess surgical wounds once a week and document the findings in the Treatment binder. Staff 2 continued, To assess a wound, a nurse looks at the drainage, the redness, the location, the measurements of the wound . signs and symptoms of infection include odor, drainage . Staff 2 was asked when care plans for the skin integrity of surgical wounds and an infection were revised. Staff 2 stated care plan revisions should be completed when a wound, or infection, occurs or worsens. Staff 2 reviewed the clinical record of Resident 53. Staff 2 stated Resident 53 was admitted with orders from the GACH (General Acute Care Hospital) to remove the surgical staples following surgery on the right femur. Staff 2 was unable to provide documentation the staples were removed per the orders, and Staff 2 was unable to provide documentation supporting the staff notified the physician or orthopedic surgeon regarding the surgical staples prior to removal. When asked to provide additional documentation of a skin assessment for the surgical site, Staff 2 was unable to do so. Staff 2 reviewed the Weekly Nursing Assessments and was asked if the Weekly Nursing Assessments contained documentation which included a surgical site skin assessment. Staff 2 stated, No. Staff 2 acknowledged the (potential for) infection and skin integrity of the surgical site care plans required revisions to reflect the changes in the resident's condition. Staff 2 stated there was no policy and procedure on assessing and documenting a surgical wound, or removing surgical staples. Review of the facility policy and procedure titled: Wound Care Management, dated 2018, indicated the wound documentation assessments must contain characteristics of the wound and treatment performed to the wound. Review of the facility policy and procedure titled: Comprehensive Care Plan dated 8/24/18, indicated, .The plan of care shall be individualized, based on diagnosis, resident assessment and personal goals of the resident and his/her family .The needs of the resident, goals, time frames, required services and the service settings are critical considerations in determining the plan of care.