Failure to Consistently Administer Wound Care Treatments as Ordered
Penalty
Summary
Two residents did not receive wound care treatments as ordered by their physicians, in accordance with professional standards of practice and the facility's policies and procedures. One resident, with diagnoses including peripheral vascular disease, venous insufficiency, and major depressive disorder, had physician orders for hydrocortisone cream and Aquaphor ointment to be applied to chronic ulcers on both lower legs. Review of treatment administration records showed that these treatments were frequently missed or not administered at the prescribed frequency over a period of nearly two months. The resident reported not receiving treatments consistently, and staff confirmed that the wound care orders were not followed as directed. Another resident, with diagnoses including vascular parkinsonism, adult failure to thrive, morbid obesity, and overactive bladder, was at risk for skin breakdown and had open sores on the back. This resident had physician orders for zinc oxide paste to be applied to the rear thighs and right buttock twice daily for moisture-associated skin damage (MASD). Treatment administration records indicated that these treatments were also missed or not performed at the required frequency. The resident reported that staff were not properly caring for the sores, and staff interviews confirmed the inconsistency in following wound care orders. Interviews with nursing staff, the Director of Staff Development, and the Director of Nursing confirmed that wound treatments were not consistently performed as ordered and that documentation was lacking when treatments were not administered. Facility policy required that wound care be provided according to physician orders and that the care plan be reviewed for special needs, but these procedures were not followed for the two residents identified.