Failure to Comprehensively Assess and Treat Non-Pressure Skin Wounds per Physician Orders
Penalty
Summary
The facility failed to comprehensively assess non-pressure related skin wounds for two of three residents reviewed, and did not administer wound treatments in accordance with physician orders for one resident. One resident with a surgical wound and wound VAC to the right buttock experienced a malfunction of the wound VAC device, resulting in the application of a wet-to-dry dressing without a corresponding physician order or documented provider notification. After hospital readmission, this resident returned with a suction burn injury to the periwound area, but the facility did not complete a comprehensive assessment of this new wound, nor did they transcribe or follow the detailed hospital discharge wound care orders, including specific dressing change instructions and use of alginate dressing. Documentation of wound assessments repeatedly lacked details about the new suction injury, and wound care was not performed as ordered. Another resident with a surgical incision to the right hip following orthopedic surgery was not comprehensively assessed upon admission or during subsequent wound evaluations. Initial and weekly wound assessments lacked measurements and did not include required details such as wound bed description, periwound condition, or evidence of infection. The nurse manager confirmed that the wound assessments were incomplete and did not meet the standard for a comprehensive evaluation. A third resident with a diabetic foot ulcer had weekly wound care provider notes and corresponding evaluations that included wound measurements and progress, but the documentation consistently omitted required details in the wound bed, exudate, periwound, pain, and treatment sections. Additionally, there was a failure to identify deterioration of the wound, as the wound size increased over time without documentation of this change or a comprehensive assessment of the wound's status. These deficiencies were identified through observation, interview, and document review.