Failure to Provide and Document Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care treatment and assessment in accordance with professional standards for a resident with multiple lower extremity wounds. Despite having clear orders for daily wound care, including normal saline cleansing and bacitracin with Mepore dressing, documentation showed that treatments were not administered on several specified days. There was no evidence in the medical record or nursing progress notes that the resident refused care on those days, nor was there documentation explaining the missed treatments. Additionally, the facility did not properly assess or document the condition of the resident's right lower leg wound. Nursing assessments and progress notes lacked detailed descriptions, measurements, or updates on the wound's status, making it impossible to monitor for changes. When the wound changed from a superficial state to one with 100% slough, this significant alteration was neither documented nor reported by the nurse providing care. The wound order also failed to specify treatments for each individual wound, instead clustering multiple wounds under a single order, contrary to facility policy. Interviews with the resident and staff confirmed that daily dressing changes were not consistently provided, and that wound assessments were incomplete. The DON acknowledged that wound descriptions and drainage should have been documented and that each wound should have had a separate treatment order. The lack of proper documentation and assessment led to an inability to track the wound's progression and ensure appropriate care was delivered.