Failure to Follow Wound Care Protocols
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive centered care plan. Specifically, a wound treatment was initiated without a physician's order, and there was a delay in the assessment of the wound. The facility's policy on skin care required staff to remain alert to skin changes and report areas of concern immediately to ensure prompt intervention. However, this protocol was not followed for a resident who had a wound on their left knee. The resident, who was cognitively intact and had no prior open wounds, was observed with a large adhesive dressing on their left knee, which was lifting at the corners and was undated and unlabeled. The resident reported that the dressing was applied after a tray table hit their knee, but could not recall who applied it or when. Despite the presence of the wound, there was no documented evidence of an assessment or physician's order for treatment until several days later. Staff interviews revealed a lack of awareness and communication regarding the wound, with some staff members assuming others were informed or had taken action. The Director of Nursing and other supervisory staff stated that they expected staff to report new skin findings immediately and obtain a physician's order for treatment. However, the wound was not properly assessed or documented in a timely manner, and the necessary communication and documentation protocols were not followed. This resulted in a delay in appropriate care and treatment for the resident's wound.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for the Resident Identified Upon discovery, the resident was assessed immediately by the nurse, and an incident report was completed. A provider was notified, and an order for [REDACTED]. Identification of Other Residents Who Could Be Affected No other instances of undocumented or unauthorized wound care were found. Systemic Changes to Prevent Recurrence - The Skin Care Policy was reviewed to ensure that it clearly requires: - Full documentation of any skin issues or injuries, - Immediate provider notification for new wounds, - Physician order [REDACTED]. - All licensed nursing staff will receive re-education on: - Skin assessment documentation, - Wound identification and reporting procedures, - The importance of adhering to physician orders [REDACTED]. - Weekly Shower/Skin notification sheet for all residents will be documented and submitted to the Director of Nursing (DON) or Designee for review to ensure: - All skin concerns are promptly identified, - Treatment orders are in place, - Documentation is complete and accurate. Monitoring and Quality Assurance - The Director of Nursing or designee will audit 10% of resident Shower/Skin Notification Sheets weekly for 8 weeks to ensure compliance with documentation, physician orders, and care plan accuracy. - Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. - After 8 weeks of 100% compliance, monitoring will transition to monthly audits for 3 additional months. Responsible Person: Director of Nursing or Designee