Failure to Implement and Document Wound Care Orders for Resident with Gastrocutaneous Fistula
Penalty
Summary
A deficiency occurred when a resident with a chronic wound at a former gastrostomy tube site did not receive necessary wound care and services as ordered and recommended by consulting specialists. The facility failed to transcribe and implement updated wound care recommendations from the stoma clinic, including the use of a specific appliance size and frequency of stoma powder application. The orders in the medical record did not match the supplies being used, and the most recent recommendations for a smaller appliance size were not reflected in the physician's orders or in the supplies available to staff. Additionally, the daily application of stoma powder, as recommended after a hospital visit for maceration, was not transcribed into the electronic medication administration record (eMAR/eTAR), resulting in missed treatments. Documentation revealed multiple missed or unsigned wound care treatments, including appliance changes and application of silver nitrate and stoma powder. The transition from paper to electronic charting further contributed to incomplete transcription of orders, and there were several instances where the required treatments were not documented as completed. Progress notes indicated ongoing maceration of the skin around the wound, but there was no evidence that the physician or stoma clinic was notified of this persistent issue, as required by facility policy. Interviews with nursing staff and management confirmed a lack of clarity regarding the current treatment orders and the rationale for appliance selection. Staff were unsure why the orders and supplies did not match, and there was no documentation that the resident or their health care proxy was educated about or involved in decisions regarding changes to the wound care regimen. The Director of Nursing acknowledged that the orders and supplies should match, and that the physician and stoma clinic should have been notified of the ongoing maceration, but this did not occur.