Failure to Follow Wound Care Orders and Timely Physician Notification
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents with non-pressure skin conditions, including surgical wounds and moisture-associated skin damage. For two residents with orders for alternating pressure mattresses, staff did not ensure the mattresses were set to the correct weight as ordered. Observations revealed that the mattresses were set to 375 pounds, while the residents' actual weights were significantly lower. Nursing staff signed off on the medication administration record (MAR/TAR) indicating the mattress settings were checked, but interviews revealed that staff did not actually verify or adjust the settings as required, instead only confirming that the mattresses were plugged in and operational. The Director of Nursing Services (DNS) confirmed that the settings were incorrect and that proper procedure was not followed. For a resident admitted with surgical wounds following a coronary artery bypass graft, the facility failed to ensure timely management and monitoring of the post-surgical wound. The resident experienced several days of excessive bleeding from a surgical site, requiring dressing changes far more frequently than ordered. Despite this, nursing staff did not notify the physician, APRN, or surgical team in a timely manner, instead only placing entries in a notification binder. Interviews with staff revealed a lack of clarity regarding responsibility for surgical wound management, with some staff believing the outside surgical team was responsible, while others indicated the facility's medical staff should have been notified. The delay in notification and assessment resulted in a lack of timely intervention for the resident's deteriorating wound condition. Facility policy required that residents with wounds be identified, assessed, and provided appropriate treatment, with ongoing monitoring and evaluation. However, the facility did not follow its own policy for surgical wounds, as the wounds were not regularly assessed or managed by the facility's physician, APRN, or wound care nurse. Documentation and interviews confirmed that the facility did not obtain or document wound culture results, and there was a lack of follow-up on changes in the resident's wound status. The failure to monitor, assess, and communicate changes in wound condition led to delays in treatment and appropriate medical intervention.