Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide wound care as ordered for a resident with a chronic left lower extremity venous ulcer and pyoderma gangrenosum. The resident had a care plan and physician orders specifying daily wound care, including cleansing, application of collagen particles, Xeroform, ABD pads, and Kerlix. Despite these orders, there was no documentation of wound care being provided or refused on four specific dates, and staff interviews confirmed that wound care was not offered or performed on those days. The nurse supervisor responsible for the resident's wound care on weekends did not provide or offer wound care, mistakenly believing the treatment was only required three times a week. She was unaware of the updated daily wound care order and had not checked the electronic medical record for new orders. The unit manager also could not recall a change in the frequency of wound care, indicating a lack of awareness and communication regarding the resident's current treatment plan. Observations revealed that the resident's wound dressing was not changed over the weekend, as confirmed by both the resident and their representative. The dressing was found with dried drainage and lacked date or initials to indicate when it was last changed. The wound nurse practitioner confirmed that the frequency of wound care had been increased to daily to ensure more consistent care, and stated that wound care should have been attempted on the missed dates.