Failure to Provide Wound Care as Ordered for Multiple Residents
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that physician's orders for wound care were implemented as prescribed for three residents. For one resident with chronic respiratory failure, dysphagia, cognitive deficits, and a Stage 3 sacral pressure ulcer, wound care orders were not followed as documented in the Treatment Administration Record (TAR). The wound care was missed on multiple days in April and May, with the Director of Nursing (DON) confirming that documentation was lacking and care was not completed as ordered. Another resident with diabetes, a recent amputation, peripheral vascular disease, and a diabetic foot ulcer also did not receive wound care as ordered. The electronic TAR (eTAR) showed that wound care for the diabetic ulcer and for moisture-associated skin damage (MASD) to the buttocks was not completed on several days in April and May. The DON acknowledged that wound care was not documented or completed as required by the physician's orders. A third resident with chronic respiratory failure, COPD, Parkinson's disease, and dementia had a skin tear to the right eyebrow. The care plan required daily wound care, but there was no evidence of an order to complete this care in the eTAR, and observations revealed the dressing was undated and the wound had dried blood. An LPN confirmed that the treatment should have been performed daily and the dressing should have been dated, but this was not done.