The breakdown in communication at Fleshers Fairview Health Care left a resident with a confirmed wound infection without proper medication while staff operated on false information about test results.
On September 11, medical staff ordered a wound culture and sensitivity test for Resident #2's left heel wound. The lab completed the test on September 14 and sent results showing infection to the facility.
But when the Wound Nurse Practitioner arrived on September 15 to treat the resident, the Wound Nurse told her the culture had come back negative.
The Wound Nurse Practitioner said she was surprised by the reported negative results. She had suspected an infection in the left heel wound during her examination. Based on what she was told, she ordered another culture and sensitivity test to be sent to the lab.
"I had suspected an infection of the left heel wound and was surprised the results were negative," the Wound Nurse Practitioner told inspectors.
She never saw the actual lab results. The Wound Nurse Practitioner said she could only access lab results if they were uploaded to the resident's electronic chart or handed to her directly.
Meanwhile, the resident's nurse practitioner had seen the positive infection results on September 17 and ordered antibiotics for the infected heel wound. But the Wound Nurse Practitioner treating the wound remained unaware.
When inspectors informed the Wound Nurse Practitioner that the wound culture completed on September 14 had actually shown infection, she realized the resident had missed treatment.
"Resident #2 had missed at least one day of antibiotic treatment because she had been provided with incorrect information for the culture and was not provided with the results on September 15," the Wound Nurse Practitioner said.
The Wound Nurse could not explain her error when questioned by inspectors on September 18.
"The Wound Nurse stated she did not know why she communicated to the Wound Nurse Practitioner that the left heel wound culture was negative on September 15," inspectors wrote. "The Wound Nurse said she had not seen the results of the culture and sensitivity that was ordered on September 11."
She had told the practitioner the test was negative without actually seeing the results.
The Director of Nursing said the facility's policy was not to give lab results to providers until all tests were completed and returned from the lab. She said Resident #2's lab results were not fully completed until September 16.
But the culture and sensitivity results had been finished by September 14. The Director of Nursing acknowledged the Wound Nurse Practitioner should have been shown those positive infection results during her September 15 visit.
"The DON stated the Wound Nurse Practitioner should have been shown the results of the culture and sensitivity results at her visit on September 15, because it was a positive result for infection," inspectors noted.
The Director of Nursing said she was unaware the Wound Nurse had given false information about the test results. In a follow-up interview, she could not explain why it happened.
"The DON stated she did not know why the Wound Nurse had told the Wound Nurse Practitioner the heel wound culture results were negative," inspectors wrote.
The Wound Nurse Practitioner said the missed day of antibiotic treatment likely did not significantly impact the wound's healing. She noted that Dakin's solution ordered for treatment on September 11 provided some broad-spectrum antibiotic coverage to the wound.
But the incident revealed a critical communication failure in the facility's wound care process. The Director of Nursing acknowledged that positive infection results should have been communicated to the Wound Nurse Practitioner on September 15 and to the resident's nurse practitioner for review.
The resident received delayed antibiotic treatment for a confirmed wound infection because staff provided false information about test results they had not actually seen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fleshers Fairview Health Care from 2025-09-22 including all violations, facility responses, and corrective action plans.
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