Failure to Provide Timely and Documented Wound Care
Penalty
Summary
The facility failed to assess, monitor, and document wound care in a timely manner for two residents, resulting in missed treatments. For one resident, an occlusive dressing on the left elbow was observed to be dated several days prior, despite treatment administration records indicating that daily wound care had been completed. Interviews revealed that the nurses who signed off on the treatments were not the ones who actually performed them, and the old dressing remained in place, indicating that the required wound care was not provided as documented. The resident had diagnoses including aphasia, hypertension, and stroke, and required assistance with activities of daily living. For another resident, a wound dressing on the right foot was found to be dated two days prior, even though physician orders required daily dressing changes. The resident had a complex medical history including sepsis, diabetes, atrial fibrillation, Guillain-Barre Syndrome, Bell's Palsy, and borderline personality disorder. The discrepancy in dressing dates and documentation suggested that at least one daily wound care treatment was missed, despite staff initially believing the dressing was dated incorrectly.