Failure to Provide Proper CVC and Wound Care per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide health care services consistent with professional standards of practice for two residents. One resident with a central venous catheter (CVC) had a dressing that was not dated and reported that the dressing had not been changed for over two weeks after dialysis was held. The resident stated that the dressing fell off and a nurse replaced it with gauze, but no formal dressing change was performed. Staff interviews revealed that only RNs were permitted to change CVC dressings, and there was no current order for dressing changes after dialysis was paused. The facility did not have a policy for care of hemodialysis CVCs, and there was a lack of clear direction or physician orders for ongoing site care after dialysis was discontinued. Another resident with a pressure injury on the coccyx area did not have a physician order for wound care, and the treatment administration record did not document any wound care provided. Staff interviews indicated that nurses occasionally applied zinc cream to the area, but there was no consistent documentation or evidence of provider notification or wound care orders. The facility's policy required wound care to be performed according to physician orders and documented in the clinical record, but these steps were not followed, resulting in the wound being overlooked.