Failure to Administer and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency was identified when a resident with chronic venous hypertension, lymphedema, and chronic kidney disease did not receive wound care treatments to bilateral lower extremity ulcers as ordered by the physician. The resident's care plan required treatments to be administered as ordered and for refusals to be documented and addressed, but there was no evidence in the care plan or medical record that the resident refused care. Physician orders specified cleansing the wounds with normal saline and applying Medi honey gel every evening shift, but multiple dates were identified where the treatment was not documented as completed. Observations revealed the resident's wounds were uncovered or not dressed as ordered, with visible open ulcers and dried drainage present. The resident reported that wound care was not consistently performed and that dressings were not applied on certain days. Review of treatment administration records and nursing notes confirmed that wound care was not documented as completed on several dates, and there was no documentation of resident refusal or alternative interventions. Skin and wound assessments indicated deterioration of the wounds during the period when treatments were missed. Interviews with nursing staff and facility leadership confirmed that treatments were not completed or documented as required. Staff acknowledged that the physician's orders were not always followed, and that documentation was incomplete when treatments were missed or not performed. Facility policy required all treatments to be administered as ordered and refusals to be documented, but these procedures were not consistently followed for this resident.