Failure to Provide Timely Wound Care and Date Dressings
Penalty
Summary
The facility failed to provide timely wound care and ensure dressings were dated for three residents with non-pressure skin conditions. One resident was admitted with a tracheostomy stoma covered by a bandage dated from the hospital, which remained unchanged for two days after admission. There were no wound care orders in place upon admission, and the dressing was not assessed or changed until several days later. Staff interviews revealed confusion about who was responsible for entering wound care orders, and documentation confirmed that wound care was not performed or recorded until after a delay. Another resident was observed with an undated dressing on the left side of the neck, and the resident was unsure when the dressing had last been changed. Physician orders specified daily wound care, and the treatment administration record indicated that care was provided, but the dressings were not dated as required. Staff interviews confirmed that dressings should be dated and changed if soiled, but this was not consistently done. The facility's policy and wound care protocol both required documentation and dating of dressings, but these procedures were not followed. A third resident was observed with undated and visibly soiled bandages on the upper extremities, including a wet bandage with dark red liquid seeping onto the bed sheets. Orders were in place for regular wound care, but there was no documentation of the soiled bandages being addressed. Staff interviews indicated that bandages were not being dated and that soiled dressings were not changed promptly. The medical director and regional nurse both stated that bandages should be clean, dry, and dated, and that staff should notify the physician if dressings are repeatedly soiled, but these expectations were not met.