Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure ulcer (PU) for a resident, as ordered by the physician. The resident, who was admitted with diagnoses including aftercare following replacement surgery and type 2 diabetes, required assistance with activities of daily living and was identified at risk of developing pressure injuries. Despite having a care plan in place, the facility did not perform the required treatment on specific dates, and the physician's orders for additional medications were not included in the resident's care plan. The resident's medical record indicated a new open area was noted, and the physician was notified, resulting in new treatment orders. However, the Treatment Administration Record (TAR) and progress notes showed that care was not performed on certain days. The Licensed Practical Nurse (LPN) involved admitted to not checking the physician's notes for new orders and acknowledged the oversight in not updating the resident's orders with the recommended medications. The Director of Nursing (DON) confirmed that the facility had a system in place for wound care, but the care nurse did not follow through with the physician's recommendations for the resident. The facility's policy required documentation of treatments performed according to physician orders, but this was not adhered to, as evidenced by the lack of documentation on the TAR and progress notes for the specified dates.
Plan Of Correction
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/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #9 was gathered through a historical document review and interview process. On the nurse contacted the physician for resident #9 who gave orders for with, C and as recommended. On the physician for resident #9 assessed the areas of skin with continued healing noted. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On the Director of Nursing/designee completed a 14 day look audit of active residents requiring care to identify other residents having the potential to be affected to ensure: 1. Treatments were performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental, were communicated with the physician and implemented in accordance with physician orders. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On, the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental, are communicated with the physician and implemented in accordance with physician orders. Newly hired licensed nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents requiring care 3 times weekly X 4 weeks and then weekly X 2 months to ensure: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental, are communicated with the physician and implemented in accordance with physician orders. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.