Failure to Provide Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to provide wound treatments as ordered by physicians for two residents. One resident, with diagnoses including peripheral vascular disease, osteoarthritis, chronic kidney disease, venous insufficiency, and mild protein-calorie malnutrition, had physician orders for wound treatments to be completed every Monday, Wednesday, and Friday. Documentation and staff interviews confirmed that wound treatments were missed on multiple occasions, including specific dates in March, April, and May. Staff members acknowledged that treatments were not performed as ordered, citing reasons such as being pulled in multiple directions and personal injury. Another resident, diagnosed with pleural effusion, peripheral vascular disease, protein-calorie malnutrition, and chronic obstructive pulmonary disease, also had physician orders for wound treatments to be performed three times a week. Review of the treatment administration record showed that none of the ordered wound treatments were performed on at least one specified date. Facility policy requires licensed nurses to follow physician orders and document care in a timely manner, which was not adhered to in these cases.