Failure to Provide Proper Wound Care and Documentation
Penalty
Summary
Surveyors identified that the facility failed to provide quality wound care for three residents, as evidenced by observations, interviews, and record reviews. One resident was observed with undated white bandages on both lower legs, despite physician orders specifying wound care procedures and dressing changes for skin tears on both legs. Another resident was seen with a bandage on the left forearm that was not dated according to the daily dressing change order. A third resident had a discrepancy between the handwritten wound care order and the electronic medical record, resulting in a delay in the initiation of the prescribed wound care regimen for a surgical wound on the right hip. Interviews with the ADON and DON confirmed that bandages should be labeled with the date, nurse's initials, and shift, and that nurses are responsible for entering handwritten orders into the electronic medical record. The facility was unable to provide a policy related to wound care when requested. The deficiencies were directly related to the failure to follow physician orders for wound care, improper documentation and labeling of dressings, and a lack of timely implementation of wound care orders.