Failure to Provide Physician-Ordered Wound Care and Monitor for Infection
Penalty
Summary
The facility failed to provide physician-ordered dressing changes, assess wounds during dressing changes, monitor for signs and symptoms of worsening infection, notify the physician of changes in condition, and acquire necessary dressing change supplies for three residents. In one case, a resident with a history of chronic venous hypertension, severe sepsis, and multiple lower extremity ulcers did not receive daily dressing changes as ordered, and wound assessments were not completed with each dressing change. There were missed wound assessments and treatments on several dates, and staff did not notify the physician when the wound increased in size or when there were changes in wound characteristics such as increased drainage, odor, and pain. The resident experienced increased redness and pain, which was not promptly assessed or communicated to the physician, and antibiotics were not administered in a timely manner despite being available in the facility's emergency kit. Another resident with severe cognitive impairment, osteomyelitis, pressure ulcers, and on hospice care did not consistently receive dressing changes as ordered. Documentation was lacking regarding whether dressing changes were completed, and wound dressings were not dated or initialed as required by professional standards. Staff interviews revealed inconsistent communication about supply shortages and a lack of clear processes for ensuring that dressing supplies were available and accessible to all staff, particularly on weekends. Additionally, staff demonstrated a lack of knowledge regarding the identification and monitoring of sepsis, with some nurses unaware of the specific criteria for early recognition. There was also a failure to document baseline assessments after residents returned from wound clinic visits, and staff did not consistently monitor or document changes in residents' conditions, including signs of infection or sepsis. These deficiencies were observed through interviews, record reviews, and direct observation, and affected the care and treatment of all three residents reviewed.