Failure to Follow Wound Care Orders Resulting in Resident Harm
Penalty
Summary
The facility failed to follow written wound care orders for a resident who was admitted with third-degree burns on the right foot, type 2 diabetes, and recent surgical aftercare. Upon admission, the resident's hospital discharge summary and care plan included specific instructions for wound care, including the use of bacitracin and xeroform dressings, daily washing, and dressing changes. However, documentation and interviews revealed that these orders were not consistently followed. The Treatment Administration Record (TAR) showed no wound care was signed off for two consecutive days, and there was no PRN order for wound care in the TAR. Staff interviews indicated confusion about the wound care orders, with some nurses expressing discomfort or lack of familiarity with the severity of the wounds, and others admitting to not performing wound care as required. The resident and family members reported that wound care was rarely performed, dressings were not changed or washed as ordered, and wound care was sometimes conducted in unsanitary conditions, such as on the floor of the resident's room. The wound care nurse admitted to removing a dressing that was supposed to remain in place and to not having the required bacitracin ointment available, substituting A&D ointment without notifying the provider or obtaining new orders. Communication lapses were evident, as the facility did not inform the hospital or the Director of Nursing about the lack of bacitracin, and the wound care nurse did not consistently document wound care in the TAR, instead making late entries in progress notes due to computer issues. As a result of these failures, the resident's wounds declined, leading to infection, increased pain, and ultimately hospital readmission for wound cellulitis and additional surgical intervention. Laboratory results showed elevated white blood cell counts, and wound cultures were positive for multiple organisms. The resident, his family, and clinical staff all described a pattern of missed or improperly performed wound care, lack of adherence to physician orders, and inadequate documentation, which directly contributed to the resident's deteriorating condition and need for further hospitalization.