Failure to Provide and Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide wound care treatments in accordance with physician orders for four residents. For one resident with diagnoses including diabetes, hypertension, osteomyelitis, and chronic kidney disease, the Treatment Administration Record (TAR) showed that wound care for a right foot stump was not documented as provided on three specific dates, despite active orders for daily or every-other-day treatment. Another resident with low back pain, congestive heart failure, and hypertension had no documentation of ordered wound care for a left heel wound on three separate dates, as indicated by the TAR. A third resident, diagnosed with diabetes, chronic obstructive pulmonary disease, and dysphagia, had no documentation of wound care for a left great toe on two dates, despite an order for daily treatment. The fourth resident, with subdural hemorrhage, gangrene, and on palliative care, had no documentation of wound care for a gangrenous toe on one date, even though the order specified treatment every 48 hours. In each case, the TAR lacked evidence that the prescribed wound care was performed as ordered. Interviews with the Treatment Nurse and the Director of Nursing confirmed that the wound treatments were not documented or administered on the specified dates for all four residents. The facility's policy requires that all treatments and procedures be documented in the resident's medical record, including details such as date, time, procedure, assessment, and the signature of the individual providing care. The absence of documentation and confirmation from staff indicated that the required wound care treatments were not provided as ordered.