Failure to Provide and Document Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received wound care in accordance with physician orders. The resident, who had diagnoses including heart failure, cellulitis, diabetes with ulcers, obesity, and muscle weakness, was admitted with a care plan requiring treatment as ordered and weekly skin checks. Physician orders specified detailed wound care steps for ulcers on the left lower extremity and right inner calf, to be performed daily or twice daily. However, clinical record review showed that wound care for both areas was not documented as performed or refused on multiple identified dates. Interviews with facility staff confirmed that wound care was the responsibility of licensed nurses, and that refusals or missed treatments were to be documented and reported. The Director of Nursing acknowledged that there was no evidence in the Treatment Administration Record to support that wound care was provided or refused on the specified dates, and that facility expectations for documentation and care were not met. Facility policies required accurate documentation of care and resident condition, as well as resident participation in care planning.