Failure to Follow Physician's Order for Diabetic Wound Care
Penalty
Summary
The facility failed to adhere to a physician's order for the treatment of a diabetic wound on a resident's left lateral foot. The resident, who has End Stage Renal Disease and diabetes, requires hemodialysis three times a week. The physician's order, dated March 14, 2025, specified that the wound should be cleansed with normal saline solution, covered with collagen, and dressed daily and as needed. However, the Treatment Administration Record for April 2025 showed that the wound care was not performed on April 3, 6, 10, 11, and 12. On April 3 and 12, the treatment was not done due to the resident's leave of absence for dialysis, but there was no documentation explaining the lack of treatment on April 6, 10, and 11. An interview with the Director of Nursing confirmed that the wound care was not administered on the dialysis days of April 3, 10, and 12, but the DON could not provide documentation for the missed treatments on April 6 and 11, which were non-dialysis days. This oversight indicates a failure to follow the prescribed wound care regimen, as required by the physician's order, for the resident's diabetic wound.
Plan Of Correction
1. Facility cannot retroactively provide wound care to a resident 37 left lateral foot. Wound treatment orders for resident 37 were changed to daily treatment dressing changes to time when not at dialysis. 2. Current and new admit dialysis residents with wound orders could be at risk for wound care during dialysis. Facility audit of dialysis residents was completed to ensure no treatments are to be done when a resident is at dialysis. 3. DON, or designee, will educate licensed staff on policy for wound care and documentation. 4. DON, or designee, will perform random audits on wound treatment care and documentation to ensure treatments are being completed weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.