Failure to Provide and Document Ordered Wound Care Treatments
Penalty
Summary
A resident with multiple complex medical conditions, including acute respiratory failure, MRSA infection, bacteremia, infective endocarditis, diabetes with foot ulcer, and congestive heart failure, was re-admitted to the facility with several unstageable pressure ulcers and diabetic foot ulcers. The care plan and physician orders specified daily wound care treatments for multiple wound sites, including the sacrum, heels, and feet, with specific instructions for cleansing, application of topical medications, and dressings. The resident's cognitive status was intact, as indicated by a BIMS score of 15. Despite these orders, documentation revealed that wound care treatments were not administered on multiple dates. The Medication and Treatment Administration Record (MAR/TAR) showed no evidence of wound care on certain days, and for several other dates, wound care orders were marked as "Hold/See Nurse Notes." Nurse notes indicated that the resident was often not in their room or on the unit at the time of scheduled treatments, or refused treatment, but there was no evidence that staff made follow-up attempts to provide care at a later time, coordinated with the resident for an alternate time, or communicated with the following shift to ensure treatments were completed. There was also no documentation of resident education regarding the importance of wound care or any modification of the care plan in response to missed treatments. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to follow physician orders, attempt to locate the resident, and reschedule treatments if the resident was unavailable or refused at the scheduled time. However, the clinical record lacked evidence of these follow-up actions. Facility policies required that wound care be administered as ordered, documented at the time of administration, and that interventions be modified as needed based on the resident's condition. The failure to provide wound care as ordered and to document follow-up actions constituted a deficiency in the provision of necessary treatment and care.