Failure to Provide Wound Care per Physician Orders
Penalty
Summary
A deficiency occurred when wound care for a resident with multiple wounds related to diabetes and poor circulation was not performed according to the physician's ordered frequency. The facility's policy required wound treatments to be provided as ordered and documented in the electronic health record. However, review of the resident's treatment administration record (TAR) showed that daily wound care treatments were not documented as completed on several specific dates. There was also no documentation in the progress notes to indicate that the resident was absent or refused care on those dates. Interviews with the resident and staff confirmed that wound care was not consistently provided as ordered. The resident reported that dressings were not changed every day due to staffing issues. The wound care nurse acknowledged that treatments were sometimes missed and confirmed the gaps in the TAR. The unit manager also confirmed the findings and stated unawareness of the missed treatments. These actions and inactions led to the failure to provide wound care in accordance with physician orders.