Failure to Provide Consistent Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that two residents with wounds received necessary treatment and services to promote healing, as required by their care plans and physician orders. For one resident with a history of cirrhosis who developed an arterial ulcer on the left foot, the medical record showed that after a wound infection was identified, the wound care consultant changed the treatment order to include Bactroban instead of Iodosorb. However, both the old and new treatments were administered daily on different shifts for several weeks, as the Iodosorb order was not discontinued when the Bactroban order was started. This resulted in two different treatments being performed on the same wound each day. Additionally, staff failed to follow the physician's order by applying an adhesive bandage to the arterial wound, which was not appropriate for the resident's fragile skin and caused discomfort during removal. For another resident admitted with osteomyelitis, right great toe amputation, and diabetes, the facility did not complete weekly skin assessments or follow the vascular physician's recommendations for care and treatment of a non-pressure wound on the right foot. The resident's physician orders lacked specificity regarding the treatment location, and the wound care recommendations from the consulting surgeon were not transcribed into the treatment orders. Documentation of wound measurements and descriptions was missing from the medical record, and weekly wound assessments were not consistently entered into the electronic health record. The wound nurse reported being unaware of the requirement to document wound information in the electronic health record and had not done so for several weeks. Observations and interviews confirmed that wound care practices did not align with facility policy, which required weekly assessments and thorough documentation for non-pressure wounds. The lack of clear, updated orders and incomplete documentation led to inconsistent wound care and failure to follow physician recommendations for both residents. These deficiencies were identified through record review, staff interviews, and direct observation by surveyors.