Failure to Follow and Document Physician Wound Care Orders
Penalty
Summary
The facility failed to ensure that physician orders for wound care were thoroughly followed and properly documented for two residents. For one resident with diagnoses including peripheral vascular disease, morbid obesity, and lymphedema, physician orders specified detailed wound care regimens for multiple areas of the right foot, including cleansing, application of various dressings, compression wraps, and weekly skin assessments. Record review revealed that several of these treatments and assessments were not documented as completed on specific dates, indicating a lack of adherence to the prescribed care plan. Another resident, admitted with a stage IV pressure ulcer to the right heel, type II diabetes, and edema, also had physician orders for daily wound care and regular checks of dressing placement. The resident's records showed multiple instances where wound care and dressing checks were not documented as completed on the required shifts. The care plan for this resident included monitoring and replacing dressings as needed, but the MAR/TAR lacked evidence that these interventions were consistently performed. Interviews with facility staff, including the DON and an LPN, confirmed that some treatments were missed or not documented, with the DON noting that some orders may have been completed by outside sources but could not account for all missed treatments. Facility policy requires that all medication and treatment orders be consistent with safe and effective practices, but the observed documentation gaps indicate that this standard was not met for the residents reviewed.