Missed Wound Care Treatment and Documentation Failure
Penalty
Summary
Facility staff failed to complete wound care treatment as ordered by the physician for one resident. The resident reported that wound dressing changes were scheduled for every Tuesday, Thursday, and Saturday, but the dressing change scheduled for Thursday was not performed. Observation confirmed that the last dressing change occurred on Tuesday, which was outside the prescribed schedule. Review of the treatment administration records showed an order for wound care every other evening shift, with the last documented dressing change on Tuesday and no documentation explaining the missed treatment on Thursday. The Director of Nursing confirmed that staff are expected to document all wound care, including when a dressing change is not completed, but there was no such documentation for the missed treatment.