Failure to Assess and Obtain Wound Care Orders After Hospital Return
Penalty
Summary
A resident returned from the hospital with a laceration on the right lower leg that required eleven stitches. Upon observation, the resident's wound was covered with a gauze dressing that was brown with dried blood stains and was unraveling. The resident reported that no staff had assessed the wound or changed the dressing since returning from the hospital. Three days after the resident's return, the wound dressing remained unchanged, and the same dried blood stains and unraveling gauze were observed. Review of the resident's Physician Order Sheet (POS) by both an LPN and the Wound Care Director revealed that there were no wound care orders documented for the resident's leg wound. The Wound Care Director confirmed that she had not assessed the wound since the resident's return and stated that prompt assessment and obtaining wound care orders should have occurred. The Treatment Nurse later changed the dressing and stated that she used orders from the hospital records, as no orders had been transcribed into the POS. The facility's policy requires prompt identification, documentation, and treatment for residents with skin breakdown, which was not followed in this case.