Failure to Monitor and Document Wound Vac Therapy
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation of negative pressure wound therapy (NPWT) for a resident with a history of Parkinson's disease, type 2 diabetes mellitus, and peripheral vascular disease, who was at risk for pressure ulcers and had existing wounds on the left lateral foot and ankle. Physician orders required wound vac monitoring every shift for functioning and placement, with specific instructions to follow if the wound vac malfunctioned or was off for more than two hours, including cleansing the wound and changing the dressing every 12 hours until the wound vac was replaced. However, review of clinical records revealed that wound vac monitoring was not documented as completed for the overnight shift on one occasion, and when the wound vac was removed due to a broken seal and peri-wound maceration, the required wound cleansing and dressing changes were not completed on multiple subsequent days. The resident reported discomfort and worsening of the wound after the wound vac was applied, and interviews with staff confirmed that the wound vac was removed due to a leak in the seal. The Director of Nursing stated that it was expected for nurses to monitor the wound vac every shift and notify the physician of any issues, but acknowledged that monitoring was not documented as completed. Facility policy required that all wound treatments be administered and documented as per physician orders. The failure to monitor and document wound vac therapy and to perform required wound care when the vac was off constituted the deficiency.