Brooken Hill Health And Rehab, Llc

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

During an interview on 11/07/2025 at 10:05 AM, LPN #6 stated he was one of the treatment nurses. Job duties included managing skin audits, educating aides on creams, regular skin treatments, and pressure wounds. He worked with both the Advanced Practice Registered Nurse (APRN) and surgical centers for wounds. He reported had no wound nurse certification, and his wound specific education comes from hands on work over the last couple of years. When preforming wound care a nurse should observe for signs of dehiscence, erythema, assess for new epithelial tissue that was pink and purple, or if the staple sites have any signs of rejections. He stated, most of the time we don't get orders on admission to remove them, but I don't mind taking them out if the surgeon is ok with it. Resident #2 admitted on Saturday 10/25/2025, when I came in on Monday 10/27/2025 I saw the post-op orders stated staples should be removed on post-op day 10 which was the day before. There was no drainage, there was some light serosanguinous drainage of the dressing that was dry. The wound was pink with no open areas. I removed the staples with no dehisced. I removed them first thing in the morning and about 3-4 hours later I got called that the wound dehisced. It was about 2-2.5 inches long at the top and deep enough you could put fingers in there. No one else looked at it prior to me removing the staples. I heard she had a coughing fit and felt her dressing leak.

A review of Resident #2's Operate Note dated 10/28/2025 revealed, a preoperative diagnosis of dehiscence of postoperative wound of abdomen and a postoperative diagnosis of dehiscence of postoperative wound of abdomen, findings were colon protruding through midline incision. Fascial edges mildly debrided and primarily closed. Onlay vicryl mesh (for temporary wound or organ support) placed.

During an interview on 11/07/2025 at 10:30 AM, the APRN stated she would not have typically seen Resident #2 for wound care because she does not see surgical incisions unless the surgeon has released

the wound to them. Saturated dressings (covering a wound) may not be a sign of infection, but an underlining pocket. If the dressings are saturating, or the edges are separated, then it would be appropriate to let the surgeon know. They could have called me as a resource, I am always available, but I would have referred them to the surgeon.

During an interview on 11/07/2025 at 12:07 PM, the Director of Nursing (DON) stated admissions were usually completed by the admission nurse, but the DON did not know who completed Resident #2's on that Saturday. The care of the wound would be the responsibility of the treatment nurse or the charge nurse for

the day. Wound care should start with the orders, and documentation in the Electronic Health Record (EHR). The treatment nurse should track all the wounds in the building.

During an interview on 11/07/2025 at 12:33 PM, the Administrator stated on a Saturday the nurse on duty would do an assessment and the treatment nurse would follow up when they came in.

During an interview on 11/07/2025 at 1:02 PM the Medical Director stated he would think an RN would have more knowledge than an LPN. He did not remember staff contacting him on Saturday, it would have been an on-call provider. If the resident was admitted over the weekend the Medical Director assumed somebody like the Assistant Director of Nursing (ADON) would make sure the wound was ok.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet