Failure to Obtain Wound Consultation, Maintain Wound Care, and Ensure Accurate Documentation
Penalty
Summary
The facility failed to obtain a wound consultation and assessment by a Wound Provider Specialist (WPS) for a resident admitted with multiple risk factors for poor wound healing, including Type II diabetes mellitus, peripheral vascular disease, and a chronic non-pressure ulcer of the right ankle. Despite the resident's complex medical history and the presence of surgical and arterial wounds, there was no documentation of a WPS evaluation from admission through the resident's discharge. Nursing staff noted that the resident was supposed to be seen by the WPS, but the consultation did not occur, and the resident's wounds and skin integrity were not evaluated by a specialist. Additionally, the facility did not ensure that wound dressings were monitored and maintained according to physician orders. The resident exhibited behaviors such as removing wound dressings due to discomfort, leaving wounds exposed. Nursing staff acknowledged that dressings were often found removed during their shifts, and there was no care plan developed to address the resident's behavior of removing dressings. The facility's Director of Nursing confirmed that staff should have reapplied dressings to keep wounds clean and dry as ordered, but this was not consistently done. The facility also failed to maintain accurate and objective documentation in the Treatment Administration Record (TAR). The TAR indicated that all skin treatments were documented as given, even on dates when the resident was no longer present in the facility due to transfer to an acute care hospital. The Director of Nursing identified this as fraudulent documentation, as it did not reflect the resident's actual presence or care provided. These deficiencies were contrary to the facility's policies and procedures regarding wound care, documentation, and consulting physician practices.