Failure to Follow Physician Orders for Wound Care and Incomplete Documentation
Penalty
Summary
The facility failed to provide wound care services in accordance with physician orders and professional standards of practice for one resident. The resident, who was admitted with diagnoses including pneumonia and venous insufficiency, had a physician's order for daily wound care to the left calf, specifying the use of oil emulsion dressing, ABD, and Kling, with the dressing to be checked each shift and replaced if missing. Documentation in the Treatment Administration Record showed that wound care was only recorded as completed on select days, with no documentation for at least two days when care was required. Facility policy required that all dressing changes be marked with the date, time, and staff initials, and that wound care be documented at the time of completion. A family member reported concerns after observing that the resident's wound dressing was not changed as ordered, with the dressing dated several days prior to their visit. Staff witness statements confirmed that wound care was not consistently performed as documented, with one LPN acknowledging uncertainty about whether the treatment was completed and another confirming that documentation was signed off without the care being provided. The Nursing Home Administrator confirmed that staff failed to consistently perform and document wound care in accordance with physician orders and facility policy.