Failure to Administer and Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure that wound treatments were administered as ordered for three out of six sampled residents with pressure ulcers. On the specified date, the Treatment Administration Records (TARs) for these residents showed that multiple physician-ordered wound care treatments, including topical medications and dressings, were not administered during the day shift. This was confirmed through both record review and interviews with the treatment nurse and the Director of Nursing, who stated that if treatments were not documented, they were not performed. The residents involved had significant medical histories and were dependent on staff for activities of daily living. One resident had metabolic encephalopathy and required a gastrostomy tube, with several pressure ulcers present upon admission. Another resident had hemiplegia and hemiparesis following a cerebral infarction, was severely cognitively impaired, and also had a pressure ulcer on admission. The third resident had similar neurological deficits and was admitted with a left heel scab. All three residents had specific wound care orders, such as Betadine, Santyl, zinc oxide, Vitamin A&D ointment, and Medi honey dressings, which were not administered as scheduled. Facility policies and job descriptions reviewed indicated that medications and wound care treatments were to be administered as prescribed and documented in the medical record. The failure to provide and document these treatments as ordered was acknowledged by both the treatment nurse and the Director of Nursing during interviews. The deficiency was limited to the lack of administration and documentation of wound care treatments for the affected residents on the specified date.