Failure to Perform and Document Wound Treatments as Ordered
Penalty
Summary
The facility failed to perform wound treatments as ordered for three residents, as evidenced by interviews and record reviews. One resident reported not always receiving dressing changes to his left knee as prescribed, with treatment administration records (TARs) showing multiple days in May and June without documentation of the required wound care. This resident had a history of left knee pain, morbid obesity, and a left artificial knee joint, and was assessed as cognitively intact but requiring assistance with mobility and hygiene. Another resident stated that dressing changes to his left middle finger were not performed daily as ordered, with TARs indicating several days in June and July without documentation of the treatment. This resident had diagnoses of type 2 diabetes and hypertension and was at risk for skin complications due to a cerebrovascular accident and malnutrition. A third resident reported that staff did not change the dressing on his left lower leg daily, sometimes going multiple days without a change. Review of TARs for this resident, who had cellulitis and congestive heart failure, showed several days in June and July without documentation of the required dressing changes. Facility staff, including the DON and wound nurse, confirmed that dressing changes are to be documented on the TAR as soon as they are completed, and that lack of documentation would indicate the treatment was not performed. The facility's policy requires consistent implementation of wound monitoring and documentation protocols.