Failure to Implement Physician's Orders for Wound Care
Penalty
Summary
The facility failed to implement physician's orders for a resident with multiple medical conditions, including atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus. The resident, who also had cognitive impairment, was found to have multiple bilateral lower extremity wounds from frostbite. A physician's order required daily wound care, including soaking the feet, applying betadine, and using specific dressings. However, the Treatment Administration Records indicated that the wound care was not performed as ordered on several occasions. This was confirmed by the Nursing Home Administrator during an interview.
Plan Of Correction
1. Wound care was completed for resident 249 on 3/4/25. Nurses on assignment were re-educated. Wound doctor assessed residents wound on 3/5/25 and there were no signs of an infection, or any harm caused to the resident. 2. DON/ADON conducted an audit on all wounds in-house to ensure they were completed and orders followed on 3/4/25. 3. IDT reviewed and updated the facility wound care policy. DON/designee provided education on the updated wound policy to licensed nursing staff. 4. DON or Designee will complete weekly wound audits to ensure wound care is being provided as ordered. Audits will be conducted weekly x2, and monthly x1. Results will be reviewed at QAPI.