Failure to Provide Proper Wound Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate care and treatment for multiple residents, as evidenced by observations, interviews, and record reviews. For one resident with multiple abdominal and limb dressings, there were inconsistencies and omissions in wound care documentation and execution. The resident reported that dressings were last changed several days prior, and staff were unaware of all wound sites. Physician orders for wound care were not consistently followed, and some dressings lacked required labeling with date and initials. Staff interviews revealed a lack of clarity regarding responsibility for wound care on weekends and incomplete skin assessments upon admission. Another resident was observed with a dressing on her limb that had a dried dark substance and was missing date and initials, contrary to facility policy and physician orders. The resident stated the dressing was due to an injury, but the required documentation and proper dressing maintenance were not evident during multiple observations. The Director of Nursing confirmed that all dressings should be dated and initialed, which was not done in this case. Additionally, a third resident's medication was held by nursing staff without appropriate parameters or physician clarification, as indicated by the Medication Administration Record and staff interviews. The DON acknowledged that the medication was held without proper orders, and the facility's policy requires medications to be administered according to prescriber orders and standards of practice. These findings demonstrate failures in following professional standards, care plans, and physician orders for both wound care and medication management.