DELMAR, NY - A licensed practical nurse at Bethlehem Commons Care Center falsely documented completing wound care treatment while leaving a cancer patient's surgical dressing unchanged for multiple days, according to a federal inspection conducted in January 2025.
Surgical Patient Left with Days-Old Dressing
The violation involved Resident #34, a cognitively intact patient admitted following abdominal surgery complications related to a history of large intestine cancer. During the January 13 inspection, surveyors discovered the resident's abdominal dressing contained dry, brown-colored drainage and was dated January 11 - two days prior.
The resident told inspectors they felt nursing staff was not monitoring their surgical incision properly. Medical orders required daily evening wound care including saline cleansing, wet-to-moist gauze application, and fresh dressing changes.
The resident stated they did not feel facility nursing staff was monitoring their incision and abdomen the way they should be.
Nurse Admits to Documentation Fraud
Licensed Practical Nurse #8 had signed treatment records indicating wound care was completed on January 12, but inspection revealed the dressing remained unchanged from January 11. When confronted, the nurse admitted to clicking the treatment as "done" before actually performing the care.
During interviews, the nurse stated they were called away to handle a patient emergency requiring hospital transport. They acknowledged clicking the documentation as complete with intentions to return and perform the actual wound care - but never did.
"They did click it as being done before it was done, and their intention was to go back in the room and change the dressing," the nurse told inspectors.
Medical Risks of Delayed Wound Care
Post-surgical wound care requires strict adherence to prescribed protocols to prevent complications. Wet-to-moist dressings maintain optimal healing environments by keeping wound beds appropriately hydrated while removing dead tissue during dressing changes.
Delayed dressing changes can lead to several serious complications: - Bacterial contamination and infection - Delayed wound healing - Tissue breakdown and necrosis - Wound dehiscence (reopening) - Systemic infection requiring hospitalization
For cancer patients like Resident #34, proper wound management is particularly critical as compromised immune systems increase infection susceptibility and healing complications.
Management Response and Disciplinary Action
The facility's Director of Nursing told inspectors that Licensed Practical Nurse #8 received a final written warning immediately upon discovery of the falsified documentation. However, supervisory staff were unaware of both the documentation fraud and the resident's concerns about inadequate wound monitoring.
Registered Nurse #2 stated they were only certain about one dressing change occurring during wound rounds on January 20 - eight days after the falsified documentation incident.
Quality Assurance Committee Failures
The inspection also revealed systemic quality oversight problems at Bethlehem Commons. The facility's Quality Assurance and Performance Improvement committee failed to include required members during monthly meetings throughout 2024.
Federal regulations require nursing homes to maintain quality committees including: - Administrator (chairperson) - Medical Director or designee - Director of Nursing - Infection Preventionist
Review of six months of meeting records showed no evidence the Medical Director or designated representative attended any 2024 meetings. The Infection Preventionist also failed to attend meetings, with the Director of Nursing acknowledging they were serving dual roles inappropriately.
Widespread Infection Control Violations
Inspectors documented multiple infection prevention failures affecting many residents across all four facility units:
Personal Protective Equipment violations: Staff failed to properly don and remove protective equipment when entering rooms requiring transmission precautions.
Equipment contamination: Oxygen tubing was observed on the floor in one resident's room, while urinary catheter bags touched the floor in multiple instances - creating direct contamination pathways.
Catheter care deficiencies: Resident #364's catheter care was not maintained according to medical orders, increasing urinary tract infection risks.
Industry Standards for Wound Documentation
Federal nursing home regulations require accurate documentation of all treatments provided. Falsifying medical records undermines patient safety by preventing proper care coordination and masking potential complications.
Best practices for post-surgical wound management include: - Visual wound assessment before each dressing change - Documentation of wound appearance, drainage, and healing progress - Immediate reporting of concerning changes to physicians - Sterile technique during all wound care procedures
Facility's Acknowledgment of Problems
Administrator #1 acknowledged monthly quality meetings were held but accepted responsibility for ensuring proper attendance documentation. They expressed surprise at learning the Infection Preventionist role could not be combined with Director of Nursing duties.
The Director of Nursing stated efforts were underway to promote a nurse to Assistant Director of Nursing, hoping this individual already possessed infection prevention certification or would receive appropriate training.
Patient Safety Implications
The combination of falsified wound care documentation and systemic quality oversight failures created an environment where patient safety risks could persist undetected. For vulnerable populations like post-surgical cancer patients, such lapses can have serious health consequences.
Proper wound healing typically occurs in predictable phases requiring consistent monitoring and intervention. Disruptions to prescribed care protocols, especially when undocumented, can result in complications requiring emergency medical intervention or prolonged recovery periods.
The inspection findings highlight the critical importance of honest documentation and robust quality assurance systems in protecting nursing home residents from preventable complications and ensuring they receive prescribed medical treatments.
Bethlehem Commons Care Center must submit corrective action plans addressing all identified violations to state regulators before the facility can demonstrate compliance with federal safety standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethlehem Commons Care Center from 2025-01-23 including all violations, facility responses, and corrective action plans.
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