Failure to Complete Weekly Skin Checks and Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that weekly skin checks were completed as care planned, wound treatments were performed according to physician orders, and that physician orders for skin impairment treatments were clarified. A resident with multiple diagnoses, including a post-procedural hematoma, open wound of the left arm, end stage renal disease, malnutrition, and heart disease, was affected. The resident's care plan required weekly skin checks, monitoring of skin impairments, and administration of wound treatments as ordered. However, medical record review showed no documentation of weekly skin checks over a period of more than a month. Additionally, there were multiple active wound care orders, some of which conflicted with the most recent surgical follow-up recommendations, and staff continued to sign off on orders for suture monitoring even after the sutures had been removed. Observations and interviews revealed that the resident's wound dressing was saturated and that the resident reported wound care was not being performed as ordered. The Treatment Administration Record indicated that staff were signing off on completion of wound care orders, despite evidence that not all orders were being followed or updated to reflect the current wound status. The RN Divisional Director of Clinical Operations confirmed the lack of weekly skin checks and the presence of conflicting and outdated wound care orders. Facility policies required staff to follow physician orders and provide appropriate wound care, but these were not adhered to in this case.