Failure to Maintain Continuous Wound Vac Suction as Ordered
Penalty
Summary
The facility failed to provide wound care treatment consistent with professional standards of practice for a resident with a surgical wound following the removal of an infected fistula. The resident had a wound vac ordered to be applied at 120 mmHg continuous suction, with a PRN order for a wet to dry dressing if the wound vac was not in use. Multiple observations and interviews revealed that the wound vac was frequently not hooked up to suction as ordered, including after the resident returned from a doctor's appointment and during various times throughout the day. The wound vac pump was found unplugged and not attached to the resident, and the canister was not present during outings, despite the device being portable and equipped with a battery pack. Staff interviews confirmed that the wound vac was supposed to be in use and on suction at all times, except for brief periods such as during showers or if a wet to dry dressing was applied. Both the RN and Treatment Nurse acknowledged that the wound vac was left off on several occasions, and the Treatment Nurse reported having observed and reported this issue previously. The Interim DON and Nurse Practitioner also confirmed that the wound vac should have been continuously in use, and that staff were responsible for ensuring it was functioning as ordered. The resident did not refuse the treatment, and there was no documentation of discomfort or refusal. The resident's medical history included Type 2 Diabetes Mellitus, hypertension, end-stage renal disease on dialysis, impaired mobility, and a recent abscess of the left upper extremity. The care plan and physician orders specified the use of the wound vac at all times, with clear instructions for alternative dressing if the device was not in use. Despite these orders and the resident's complex medical needs, the facility did not consistently follow the prescribed wound care protocol, as evidenced by multiple staff and family reports, as well as direct observation.