Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to monitor and ensure proper treatment of wounds and complete weekly skin assessments for two residents. Resident R4, who was admitted with a chronic abdominal wound, did not have documentation of the wound for specific weeks, and the wound, initially marked as healed, reopened. Despite the reopening, there was a lack of consistent documentation and monitoring as required by the facility's policy. The Nursing Home Administrator confirmed the failure to adhere to the required monitoring and assessment protocols. Resident R199, admitted with a pressure ulcer and a surgical wound, had physician orders for wound care that did not specify which treatment was for which wound. This lack of clarity in treatment orders led to confusion in the application of wound care, as confirmed by the Registered Nurse Assessment Coordinator. The facility's failure to specify treatment for each wound compromised the proper care and management of Resident R199's conditions.
Plan Of Correction
Resident #199 wound treatment order was immediately clarified and discontinued per physician. Resident #4 wound treatment order was clarified, skin assessment performed, measurements were documented, and physician notified of findings. To identify other residents that have the potential to be affected, the DON/designee conducted a house audit on all resident wound orders to ensure proper treatment of resident wounds and weekly skin assessments. Any negative findings were addressed. To prevent this from reoccurring, the DON/designee educated licensed nursing clinical staff on observation of skin and wound best practices and wound management. To monitor and maintain ongoing compliance, the DON/designee will review wound documentation and new wound treatment orders 5x weekly for 4 weeks, then monthly for 2 months to ensure appropriate monitoring, documentation, and reporting of resident wounds and weekly skin assessments. Negative findings will be addressed. Ad hoc education will be completed as needed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.