Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure wound dressing changes were completed per physician orders for a resident with severe cognitive impairment. The resident was admitted to the facility with orders for daily wound care on the right heel and leg, as well as instructions to offload the right heel while in bed. However, observations revealed that the resident's right heel was directly on the mattress without offloading, and the dressings on the right leg had not been changed as ordered. The dressings bore the same date and initials for two consecutive days, indicating that the dressing change had not been performed. The Unit Manager confirmed that the dressing had not been changed as documented in the Treatment Administration Record (TAR), which falsely indicated that the dressing change had been completed. When the dressing was eventually changed, it was found to have a moderate amount of drainage and was malodorous, suggesting that the wound care was not being managed appropriately. This failure to follow physician orders and accurately document care led to a deficiency in the facility's wound care management for the resident.
Plan Of Correction
F684- Quality of Care: care was not completed as ordered; care was documented as done. What corrective action(s) will be implemented for those residents found to have been affected by the deficient practice? The physician was informed by the Unit manager of the order for care not being executed, on /24 for resident #61, a new order for PRN obtained and care performed on. The resident's was evaluated by care on and showed no adverse outcome from missed care. How will you identify other residents who have the potential to be affected by the same deficient practice and what corrective action will be taken? DON and Unit managers completed an audit of all similar residents to identify any other residents affected by the deficient practice on. The audit revealed that no other residents were affected by the deficient practice. What measures will be implemented or what systemic changes will you make to ensure that the deficient practice does not recur? All licensed nurses will be reeducated on care policy and procedures and on following physicians' orders by. All licensed nurses will be reeducated on nursing documentation of provision of care in residents' medical records only after the care is completed by. Weekly quality review of care provision and documentation will be conducted by DON/designee of 5 residents with x 4 weeks then bi-weekly x 2 then monthly x 1 by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Results of quality review by DON/designee will be introduced in the QAPI process for monitoring and review for 3 months or until substantial compliance with care policy. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and for executed solely because it is required by the provisions of federal and state law.