Failure to Provide Timely and Consistent Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide appropriate wound care treatment and follow physician orders for three residents who were admitted with significant skin and wound care needs. For one resident, the admission records and physician documentation indicated multiple skin tears and wounds requiring specific dressing changes and wound care regimens. However, the treatment administration record showed that wound care orders were not implemented upon admission, and wound care was only documented once during the resident's stay. The resident's responsible party also reported that wound care was not provided consistently. Another resident was admitted with multiple pressure ulcers and wounds, including stage IV pressure areas and an unstageable wound. Physician orders and wound care consults were documented, specifying daily wound care treatments for several sites. Despite this, the facility's records lacked documentation of wound care being provided until several days after admission, and initial orders did not cover all identified wounds. The nursing admission assessment confirmed the presence of multiple wounds, but corresponding treatment orders were incomplete or delayed. A third resident was admitted for wound care with several unstageable pressure ulcers documented on admission forms and nursing assessments. Despite the clear need for wound care, the facility's records did not contain any wound care orders for this resident. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy required prompt skin assessments and obtaining physician orders for treatment upon admission, but this process was not followed for these residents. The Director of Nursing acknowledged that the facility's expectations for wound care assessment and treatment were not met in these cases.