Failure to Provide Ordered Wound Care and Weight Monitoring
Penalty
Summary
The facility failed to implement and consistently provide wound care and weight monitoring as ordered for multiple residents with complex medical needs. For one resident with a chronic venous wound and congestive heart failure, there was a delay in initiating wound treatment upon admission and after readmission, with daily wound care treatments frequently missed or undocumented over several months. Nursing staff often believed that wound care was the responsibility of the treatment nurse or aide, leading to confusion and missed treatments. The resident, who was cognitively intact and did not refuse care, reported not receiving wound care every day, and documentation confirmed multiple days where treatments were not completed or recorded. The Wound Care Physician and Medical Director were unaware that orders were not being followed as prescribed. Additionally, the same resident had physician orders for daily weights due to congestive heart failure and fluid restrictions, but daily weights were not consistently obtained or documented. The Restorative Aide, primarily responsible for obtaining weights, was sometimes unavailable due to other assignments, and nurses did not obtain weights in her absence. One nurse admitted to recording previous weights on the Medication Administration Record (MAR) without actually obtaining new weights, resulting in inaccurate documentation. The Registered Dietitian and physician confirmed that daily weights were necessary for monitoring the resident's condition, but the process for ensuring weights were obtained was not followed. For another resident with arterial ulcers and a history of amputation, wound care treatments were not completed as ordered on multiple days, particularly when there was no assigned treatment nurse. Floor nurses did not always complete or document the required wound care, and the Wound Care Nurse did not review the Treatment Administration Records (TARs) for completion. This resident also did not have weekly or daily weights obtained as ordered following readmission, despite significant changes in condition, including edema and elevated BNP levels. The Restorative Nursing Assistant, responsible for weights, reported difficulty obtaining all required weights due to other duties and a lack of a backup system or notification process for new admissions and readmissions.