Failure to Perform and Document Ordered Burn Wound Care
Penalty
Summary
A resident with multiple complex medical conditions, including paraplegia, stage 4 sacral pressure ulcer, third-degree burns to both lower legs, and chronic bowel incontinence, was admitted to the facility with physician orders for daily wound care to the right and left lower extremities. Observations revealed that the dressings on the resident's sacral area and both calves were not dated or initialed. Review of the treatment administration record showed that wound care was not performed on either lower extremity on two specific dates, despite daily orders. The resident reported that staff were not changing the dressings as required, and both a Certified Nurse Aide and the Wound Care Nurse confirmed the resident was alert and oriented, emphasizing the importance of adhering to wound care orders to prevent infection and promote healing. The Director of Nurses acknowledged that wound care should be documented immediately after being performed, and lack of documentation indicates either the care was not provided or not recorded. The facility's policy requires documentation of dressing changes on the treatment administration record or electronic health record. The failure to perform and document wound care as ordered for the resident's non-pressure wounds constituted a deficiency in providing appropriate treatment and care according to physician orders and facility policy.