Failure to Provide Wound Care per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide appropriate wound care according to physician orders and facility policy for two residents. For one resident, observations revealed a dressing on the left forearm that was changed and re-dated over several days, but there was no physician order for wound care to that area. Staff interviews confirmed that wound care was being performed without an order, and the Director of Nursing acknowledged that staff are not permitted to provide wound care without a physician's order and that dressings should be dated and initialed. For another resident, a gauze-wrapped dressing was observed on the right arm over multiple days, but the dressing was not dated or initialed, and there was no physician order for wound care to that area. Staff interviews confirmed that wound care dressings should be dated and that orders are required for wound care. Review of facility policy indicated that a physician's order is required for dressing application and that dressings should be labeled with the date and initials, which was not followed in these cases.