Failure to Assess, Monitor, and Follow Physician Orders for Wound and Positioning Care
Penalty
Summary
The facility failed to provide appropriate assessment, monitoring, and care for residents with wounds and positioning needs. One resident with a surgical wound following a left intertrochanteric femur fracture did not have evidence in the medical record of an initial nursing assessment, ongoing monitoring, or assessments of the surgical site throughout their stay. This lack of documentation and monitoring was confirmed by the Market Clinical Advisor. Another resident with an open wound on the right forearm had a physician order for topical Mupirocin and for the wound to be covered with a bandage, but was observed on two occasions with the wound uncovered. Nursing staff confirmed that the wound should be covered and that the resident does not typically refuse or remove dressings. Additionally, a resident with hemiparesis was observed using a left wrist brace as part of their care plan, but there was no physician order for the brace in the clinical record. The Director of Rehabilitation and Occupational Therapist confirmed that a physician order should be present for the brace.