Failure to Provide Timely and Appropriate Wound Care per Physician Orders
Penalty
Summary
Two residents did not receive treatment and care in accordance with professional standards and physician orders. One resident, who had a right above-the-knee amputation, experienced wound dehiscence with signs of infection. The nurse practitioner ordered antibiotics and requested a vascular consult as soon as possible, but there was no documented evidence that the consult was scheduled promptly. The resident's wound worsened, with increased dehiscence and drainage, and the resident was eventually sent to the hospital for post-operative infection and wound dehiscence. Multiple staff interviews confirmed that the request for an expedited vascular consult was not acted upon in a timely manner, and the scheduled appointment was not considered soon enough given the resident's condition. Another resident with a history of osteomyelitis, diabetes, and left toe amputations did not receive wound vacuum-assisted closure (VAC) therapy or the backup wet-to-dry dressing as ordered during a period when the primary wound care nurse was absent. Documentation showed that the VAC dressing was not changed for nearly two weeks, and there was no evidence that the backup dressing was applied as per physician orders. The resident reported that during this time, they had to cover their wound themselves and seek assistance from staff, as no one was available to provide the required wound care. Staff interviews revealed a lack of continuity in wound care coverage and documentation during the wound nurse's absence. In both cases, the facility failed to follow physician orders and ensure timely and appropriate wound care interventions. There was a lack of documentation and communication regarding changes in the residents' conditions and the implementation of backup care plans when primary treatments could not be provided. These failures resulted in harm to one resident and placed both residents at risk due to lapses in wound management and follow-up care.