Failure to Routinely Assess and Obtain Treatment Orders for Resident Wound
Penalty
Summary
The facility failed to ensure that wounds were comprehensively assessed on a routine basis and did not obtain treatment orders for a wound for one resident. The resident, who had multiple sclerosis and was admitted with a denuded area on the left buttock, was identified as having a potential for skin breakdown. The care plan included weekly skin assessments but did not list any treatment interventions for the wound. Documentation in the resident's records showed inconsistent and incomplete wound assessments, with missing details such as anatomical location, wound characteristics, and pain or symptom reporting. Progress notes and skin condition records indicated the presence of an open area on the left buttock, but assessments lacked comprehensive information as outlined in best practice guidelines and facility policy. Despite ongoing documentation of the wound, there were no physician orders for wound care in the resident's medical record during the review period. Interviews with nursing staff and the DON confirmed that the wound was not fully assessed or documented on a routine or weekly basis, and that no treatment orders were obtained for the area. This failure to follow established protocols and obtain necessary physician orders resulted in a deficiency related to the comprehensive assessment and management of wounds.