Failure to Provide Wound Care per Physician Orders
Penalty
Summary
A resident with an open fracture of the left lower leg and diabetes was admitted to the facility with specific hospital discharge instructions for surgical wound care, including the use of a honeycomb dressing, monitoring for excessive drainage, removal of staples after two weeks, and scheduled follow-up with the surgeon. Upon review, it was found that the resident's admission nursing database did not include information about the surgical site or wound care, and the medication and treatment administration records lacked any wound care or monitoring orders for the first two weeks after admission. The resident missed the required follow-up appointment, and the prescribed dressing protocol was not implemented or documented during the initial seven days post-admission. Subsequently, the resident developed new slough, increased redness, and drainage at the surgical site, leading to a diagnosis of cellulitis and the initiation of antibiotics. Further review showed that even after wound care orders were eventually entered, there were missed wound care treatments on specific days. Staff interviews confirmed that the wound was not checked or monitored upon admission, the dressing orders were not transcribed, the follow-up appointment was missed, and the sutures were not removed as ordered by the physician.