Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide physician-ordered treatment and services for a non-pressure abdominal wound for one resident. The resident developed an open area on the left lower abdomen, which was documented and assessed by nursing staff. The physician ordered daily wound care treatment, including cleansing with wound wash or normal saline, application of Xeroform dressing, and coverage with border foam, to be performed every day shift until healed. However, on a subsequent observation, the resident's wound was found to be open, partially scabbed, and without any dressing present, contrary to the physician's orders. Record review revealed that the treatment administration record for the resident showed no documentation or nurse initials indicating that the wound care was completed on a specific date. The Director of Nursing confirmed that the treatment was a current order and should have been completed and documented. The nurse responsible for wound treatments did not perform the required care on the specified date, resulting in a failure to follow the physician's orders for wound management.