Failure to Complete Physician-Ordered Wound Care for Two Residents
Penalty
Summary
The facility failed to follow physician orders for wound care for two residents with complex medical conditions. One resident, admitted with peripheral vascular disease and heart failure, had a venous/arterial ulcer and was prescribed a specific wound care regimen, including dressing changes every other day and the application of various topical treatments. Review of the Treatment Administration Record (TAR) showed that the ordered wound care was not completed on multiple specified dates across several months. Interviews with nursing staff confirmed that the treatments were missed as documented in the TAR. Another resident, admitted with diagnoses including cancer, cirrhosis, and neurogenic bladder, had multiple pressure ulcers, including a stage 3 ulcer and unstageable wounds. This resident had physician orders for daily application of Santyl ointment and specific wound care procedures. The TAR indicated that the prescribed treatments were not completed on two documented dates. Both the wound care nurse and the Director of Nursing acknowledged that the physician-ordered wound care was not completed as required. Facility policy requires wound treatments to be provided in accordance with physician orders, but this was not followed for these residents.