Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to assess, monitor, follow physician orders, and document wound care for a resident with non-pressure skin conditions. The resident, a 65-year-old male with diagnoses including hypertension, peripheral vascular disease, wound infection, and diabetes, was admitted with an unstageable wound infected with MRSA. Despite physician orders for daily wound treatments, review of the Medication Administration Record (MAR) revealed over 30 missed treatments without supporting documentation or valid reasons. Weekly wound assessments were also incomplete, with missing documentation on several dates. Interviews with staff confirmed that wound treatments and assessments were not consistently performed or documented as required. Further, the resident reported to wound clinic staff that dressings were not changed daily as ordered, and he often arrived at the clinic with dressings dated more than 24 hours prior. The wound clinic also verified that the resident was not seen for a scheduled appointment on one occasion, contradicting facility staff's belief. The Director of Nursing acknowledged the missed treatments and lack of documentation, and staff interviews confirmed that missed treatments were not always communicated to the physician or documented in progress notes as required by facility policy.