Failure to Obtain, Document, and Care Plan Wound Care Orders for Multiple Residents
Penalty
Summary
The facility failed to provide care and treatment according to physician orders, resident preferences, and established standards of practice for three residents with wounds. Staff did not obtain or enter wound care orders, did not document wound care provided, and did not update care plans to reflect current wounds and treatments. For one resident with a recent hip fracture and surgical incision, staff did not transcribe hospital discharge wound care orders into the physician order sheet or treatment administration record, nor did they care plan for the hip incision and its required care. Progress notes referenced the surgical site, but there was no documentation of dressing changes or ongoing monitoring in the treatment records. Another resident with multiple injuries, including a head laceration with sutures, returned from the hospital without documented wound care orders. Staff did not contact the physician to obtain orders for the head wound, and the care plan was not updated to reflect the most recent fall and laceration. No orders or treatments related to the head laceration were documented in the medication or treatment administration records, despite ongoing monitoring and assessment of the wound in progress notes. A third resident experienced skin tears to the right elbow and left upper extremity following falls and contact with equipment. While staff cleansed and dressed the wounds and notified appropriate parties, they did not enter treatment or monitoring orders into the physician order sheet or treatment administration record. The care plan was not updated to address these wounds, and staff interviews confirmed that wound care orders were not consistently entered or documented. The facility was unable to provide a policy regarding the process for obtaining, entering, and following treatment or monitoring orders.