Failure to Follow Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that the wound care practitioner's recommendations were appropriately addressed for a resident with wounds. The resident, who was readmitted to the facility, had a left shin wound and a right distal shin wound, both with arterial etiology and documented as full thickness wounds. The wound care practitioner recommended specific treatments for each wound, including cleansing with Dakin's solution and applying betadine for the left shin wound, and using medical grade honey and covering with border gauze for the right shin wound. However, the clinical records showed no evidence that these recommendations were communicated to or approved by the attending physician. Furthermore, the active physician's orders and the Medication Administration Record indicated that the resident received the same treatment for both shin wounds, which did not align with the wound care practitioner's recommendations. The Director of Nursing confirmed that the resident's wound care was consistent with the wound consultant's recommendations, yet the documentation and treatment records did not reflect this. This discrepancy highlights a failure in following the recommended wound care treatment plan for the resident.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R151 wound recommendations were addressed. The DON/designee audited the most recent wound report recommendations to ensure current recommendations are addressed and orders are in place. The DON/designee educated licensed staff on ensuring that the wound care practitioner recommendations are addressed and orders are in place. The DON/designee will audit the wound care practitioner recommendations to ensure recommendations are addressed and orders are in place. Audits will be done weekly x 4 weeks and then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.