Failure to Provide Consistent Negative Pressure Wound Therapy and Documentation
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with a diabetic foot wound requiring Negative Pressure Therapy (VAC). The resident had a history of Type 2 Diabetes Mellitus with a foot ulcer, recent surgical amputation, and other significant medical conditions. Physician orders required continuous VAC therapy to the right foot, with nursing staff responsible for assessing and documenting the VAC's functioning every shift. However, documentation was missing for several consecutive days, and there was no evidence that the VAC was assessed or functioning properly during this period. Progress notes and the Treatment Administration Record lacked entries confirming the required care was provided on multiple days. Interviews with nursing staff, the wound specialist, and the Director of Nursing confirmed that the VAC was not consistently monitored or documented, and that the wound care provided over the weekend was substandard. The wound specialist noted that the VAC appeared to have not been working for several days prior to her assessment, and the resident's surgical site deteriorated as a result. The DON acknowledged that the lack of documentation indicated a failure to provide care in accordance with professional standards, as required for wound healing and prevention of further complications.