Failure to Prevent, Identify, and Treat Wounds and Complete Wound Care Documentation
Penalty
Summary
The facility failed to prevent the development of new wounds, provide timely wound care, and accurately document new skin impairments for two residents. One resident, with diagnoses including peripheral vascular disease, dementia, and malnutrition, was at high risk for skin breakdown and required staff assistance for care. Despite care plans specifying weekly head-to-toe skin assessments and immediate reporting of new skin issues, there were significant lapses in documentation and assessment. Multiple wounds, including on the right lateral hip, heel, toes, lateral ankle, and lateral foot, were not identified or treated in a timely manner. There were gaps in weekly skin assessments, and no treatment orders or documentation of wound care were present until after the wounds were discovered by the resident’s daughter and the wound care coordinator. Another resident, dependent on staff for all activities of daily living and diagnosed with multiple sclerosis, had multiple pressure wounds, including stage 3 and 4 ulcers. Review of medication and treatment administration records revealed numerous omitted wound care treatments over several months. The wound nurse reported that when assigned to work as a floor nurse, other nurses were responsible for wound care, but treatments were often not completed as required. The facility’s own policy required identification, evaluation, and appropriate treatment for residents with wounds or at risk for skin compromise, but this was not consistently followed. Interviews with the wound care nurse and DON confirmed ongoing issues with timely and accurate skin assessments, reporting of changes in condition, and completion of wound care treatments. The facility acknowledged problems with staff not completing required wound care and documentation, leading to delays in treatment and lack of adherence to physician orders and care plans for residents with wounds.