Failure to Consistently Provide Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including multiple sclerosis, malnutrition, depression, and anxiety disorder, did not consistently receive prescribed wound care for a right ankle wound. The resident was cognitively intact and reported that staff were not cleaning the wound as frequently as ordered by the physician. The care plan required monitoring and documentation of the wound, as well as reporting abnormalities to the physician. Physician orders specified daily evening wound care, with changes as needed if soiled or dislodged, and later included specific wound care products. However, treatment administration records showed that wound care was missed on several specific dates. Interviews with facility staff, including the Nurse Supervisor, Director of Staff Development, and Director of Nursing, confirmed that the wound care was not performed as ordered. Staff acknowledged that failure to follow wound care orders could result in infection, delayed healing, or worsening of the wound. The facility's policies required wound treatments to be provided according to physician orders and professional standards of practice. As a result of the missed wound care, the resident experienced right ankle pain, increased bleeding, confusion, elevated heart rate, and temperature, which led to a hospital transfer. Hospital records indicated the presence of an infected wound with MRSA and Pseudomonas, requiring intravenous antibiotics. The failure to provide consistent wound care as ordered by the physician and outlined in facility policy directly contributed to the resident's condition and subsequent hospitalization.
Plan Of Correction
**Quality of Care** How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #346 right ankle wound care was completed on 04/08/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with wounds was completed on 04/11/2025 by Medical Records Director to ensure that residents had their treatments completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents treatments are done consistently. d) LN Supervisor will review treatment administration records to ensure treatments are being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: e) LN Supervisor and/or designee will review treatment administration records to ensure treatments are being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/17/2025