Failure to Ensure Wound Care Services Met Professional Standards
Penalty
Summary
The facility failed to ensure that wound care services provided to a resident met professional standards of practice, as evidenced by multiple deficiencies in the management and documentation of wound treatments. For a resident with dementia and moderate protein-calorie malnutrition, a wound physician recommended a specific treatment regimen for a non-pressure wound on the left anterior shin, including the application of a collagen sheet with calcium alginate and a gauze island dressing twice daily. However, there was no evidence of a physician's order in place for this treatment, and during observation, the dressing applied to the wound was not labeled with the date or initials as required by facility policy. Staff interviews confirmed the absence of the required order and proper labeling. Additionally, the same resident had an unstageable pressure wound on the left posterior calf. While there were physician orders for wound care, including the use of Santyl and later a collagen sheet with calcium alginate, record review showed gaps where no treatment order was in place for several shifts. The wound nurse acknowledged that orders from the wound physician are transcribed by nursing staff, but if received after hours, transcription may be delayed until the following day. The nurse also confirmed the lack of a treatment order for the non-pressure wound and the absence of documented treatment for the pressure ulcer on specific dates, as well as the failure to date and initial dressings per policy.