Failure to Provide Timely and Documented Wound Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate wound care and timely skin assessments for two residents, resulting in deficiencies related to wound management. One resident was admitted with multiple wounds, including ulcers and abrasions, and had a history of sepsis and diabetes. Despite clear documentation from the hospital and an advanced practice nurse indicating the need for wound care, the facility did not complete a timely or accurate skin assessment upon admission. Wound care orders were not obtained until several days after admission, and the resident did not receive any wound care during their stay. The treatment administration record did not align with the actual wounds present, and there was a lack of documentation for certain wounds requiring care. Another resident had a sore on the left lower shin, which was observed to have a dressing that was not initialed or dated. The medical record did not contain an order for this dressing, nor did it document the presence of a wound on the left lower shin. Skin checks in the record failed to note any skin impairments, and the wound was not included on the wound boards for review. The wound care nurse confirmed there was no documentation or treatment order for the area until after the issue was brought to attention during the survey. Interviews with staff and residents confirmed that wound care was either not provided or not documented as required. The facility's policy required verification of physician orders and documentation of dressing changes, but these steps were not consistently followed. The lack of timely assessment, absence of treatment orders, and failure to document wound care contributed to the deficiencies identified during the survey.