Failure to Complete Wound Assessments and Treatments for Residents with Non-Pressure Wounds
Penalty
Summary
The facility failed to provide appropriate wound assessments and treatments for three residents with non-pressure wounds. For one resident with a history of left foot drop, muscle weakness, and a recent toe amputation due to osteomyelitis, there was a lack of documentation regarding the assessment of a new wound on the left foot. After a verbal order for betadine treatment was received, the facility did not document the reason for the order or provide wound descriptions and measurements from the time of the order until a surgical appointment over two weeks later. Weekly skin observations during this period were incomplete, lacking details about the wound. Another resident with diagnoses including cellulitis, heart failure, and obesity was admitted with non-healing vascular wounds on both lower legs. Upon admission, wounds were noted, and care plans directed weekly documentation of wound measurements and observations. However, the treatment administration record showed several missed or undocumented wound treatments, and there were gaps in wound assessments and measurements throughout the resident's stay. Progress notes indicated delays in receiving wound care supplies, and weekly skin observation sheets lacked detailed assessments of the wounds. Facility policies required nursing staff to assess, evaluate, and document resident care, including prompt notification of physicians when changes occurred. Despite these policies, staff interviews confirmed that wound treatments and weekly skin assessments were not consistently completed as required. The Director of Nursing acknowledged the lack of additional documentation for one of the residents involved.