Failure to Follow Physician Orders and Maintain Wound Vac Function
Penalty
Summary
The facility failed to follow physician orders and maintain professional standards of quality in the care of a resident who required a wound vacuum (vac) for wound management. The physician ordered the wound vac to run continuously at 125 mmHg and to be changed every Monday, Wednesday, and Friday. However, the order was incorrectly entered into the system, directing staff to change the wound vac every 30 minutes, which was later identified and corrected by nursing staff. Documentation showed inconsistencies in the timing and completion of wound vac changes, with some treatments not performed as ordered and missing documentation for required dates. Staff interviews revealed that the wound vac was frequently unplugged while the resident was out of bed or during meals, and at times, the device was found shut off or nonfunctional. Further, staff reported a lack of education and training on wound vac use, with some nurses expressing discomfort in performing the procedure without proper instruction. There were also instances where the wound vac was not changed due to lack of supplies and management support. The resident was twice taken to podiatry appointments with either a nonfunctional wound vac or no machine at all, resulting in the wound vac dressing remaining in place without active therapy. On one occasion, the wound vac had a dead battery due to not being plugged in overnight, and the wound exhibited malodor and drainage. The physician documented concerns about the unacceptable care provided to the resident.