Failure to Complete Physician-Ordered Wound Care for Venous Stasis Ulcers
Penalty
Summary
A deficiency occurred when a resident with chronic venous hypertension and bilateral lower extremity ulcers did not receive wound care treatments as ordered by the physician. The prescribed treatment included cleansing the wounds, applying skin prep, Medihoney, Calcium Alginate, ABD pads, kerlix gauze, and ACE wrap, to be changed daily and as needed. Review of the Treatment Administration Records (TAR) for February and March revealed multiple dates where the dressing changes were not signed off as completed, indicating the treatments were not performed as ordered. Interviews with nursing staff confirmed awareness that dressing changes were sometimes missed, with staff citing staffing challenges as a contributing factor. The DON confirmed that unsigned treatments on the TAR indicated they were not completed, and was only able to account for one of the missed dates. Facility policy required treatments to be provided according to physician orders, but this was not consistently followed for the resident in question.