Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide and document physician-ordered wound care for a resident with multiple wounds and significant medical history, including paraplegia, pressure ulcers, and bilateral lower limb amputations. The resident's care plan and physician orders specified daily wound treatments for the left posterior thigh and bilateral stumps, as well as new abdominal wounds. However, the Treatment Administration Record (TAR) showed multiple dates where these treatments were not documented as completed. Additionally, wound care orders for new abdominal wounds were not entered into the system, resulting in a lack of documented treatment for those areas. Interviews with facility staff confirmed that treatments should be documented in the TAR and that it was the responsibility of the nursing staff to enter and carry out physician orders in a timely manner. The facility's own policy requires accurate and timely documentation of care provided. The failure to document and provide ordered wound care was directly observed through record review and staff interviews, confirming the deficiency.