Failure to Follow Physician Orders for Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that physician's orders for wound care were followed for two residents with pressure ulcers or at risk for pressure ulcers. For one resident with diabetes and moderate cognitive impairment, documentation showed no current skin issues, but a podiatry visit identified a stage 3 pressure ulcer on the left great toe. Despite orders for daily wound care to the right great toe, there was no evidence on the Treatment Administration Record (TAR) that any dressing changes were completed, and the wound was actually on the left foot. Observations confirmed the presence of a dressing on the left foot, and staff interviews indicated that if wound care was not documented on the TAR, it was likely not performed. Weekly skin assessments were also not up to date. For another resident with moderately impaired cognition and two stage 4 pressure ulcers, care plans and physician orders required daily wound care to the sacrum-coccyx area and scrotum. Review of the TAR revealed that wound care was only documented as completed on 16 of 31 days in one month and 7 of 14 days in the following month. Staff interviews confirmed that wound care was not completed daily as ordered, and weekly skin evaluations were inconsistently performed depending on staff availability. The Director of Nursing and Administrator acknowledged that the lack of documentation and incomplete wound care was due to inadequate staffing, which resulted in missed treatments and outdated skin assessments. There was no information in the facility's policies to support the deficient practice.