Failure to Transcribe and Implement Wound Care Orders and Notify Physician of Changes
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards for a resident admitted with bilateral groin surgical wounds. Upon admission, the resident had orders from the discharging hospital to clean the groin sites daily and to remove Silveron dressings after five days. However, staff did not transcribe these wound care orders into the resident's Medication Administration Record (MAR) or Treatment Administration Record (TAR), and there was no documentation of wound care being completed from admission through several days post-admission. The care plan was not updated to reflect the resident's wound care needs, and there was no evidence of a wound treatment or skin assessment policy being provided by the facility. Throughout the resident's stay, progress notes repeatedly documented that the resident was removing dressings and picking at the incisions, but staff did not notify the physician in a timely manner about the dressings being removed earlier than ordered or about changes in the wound condition, such as the appearance of drainage. Documentation of wound care provided was inconsistent or absent, and staff failed to record completion of wound care or reasons for non-compliance in the MAR or TAR. Communication with the physician regarding the resident's noncompliance and changes in the wounds was not documented until much later, despite ongoing issues. Interviews with facility staff, including CNAs, LPNs, the DON, and the facility physician, confirmed that wound care orders were not entered into the MAR, and that staff did not consistently document wound care or physician notifications. The physician stated that he was not notified about the early removal of dressings or the presence of drainage, and that failure to follow wound care orders could increase the risk of infection. The administrator also confirmed that wound care orders should have been entered and documented appropriately, and that weekly skin assessments and tracking should have been recorded in the electronic health record.