Failure to Provide Cholecystostomy Dressing Changes as Ordered
Penalty
Summary
The facility failed to provide cholecystostomy dressing changes as ordered by the physician for a resident with a biliary drain. The resident, who was severely cognitively impaired and had a history of chronic cholecystitis managed with a percutaneous cholecystostomy tube, had physician orders for dressing changes every twelve hours. Documentation on the Medication Administration Record indicated that the dressing was changed on a specific date by two nurses, but both nurses later stated in interviews that they did not perform the dressing change as ordered. One nurse documented the dressing change based on the assumption that a wound nurse had completed the task, but the wound nurse was not present in the facility that day and could not identify who was responsible for wound care on that date. The Director of Nursing was also unable to identify the nurse assigned to wound care on the relevant date. Further review of the Treatment Administration Record and direct observation revealed additional inconsistencies. The wound nurse documented dressing changes on subsequent days, but during an observation, the dressing was found to be dated two days prior, indicating it had not been changed as recorded. The wound nurse explained that she relied on information from a nurse aide, who had assumed another nurse had changed the dressing after hearing a comment about the sutures. However, the nurse in question confirmed she only inspected the site and did not change the dressing. The Director of Nursing confirmed that the dressing should have been changed daily per physician orders by either the wound nurse or the assigned nurse.