Failure to Document and Administer Ordered Foot Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide documented evidence that foot wound treatments were administered according to physician orders for one resident. The resident, who had diagnoses including idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, and arthropathic psoriasis, had physician orders for daily cleansing and application of Clobetasol cream to both feet. Review of the July Treatment Administration Record (TAR) revealed missing documentation for the completion of these treatments on three specific dates. The resident reported that wound care was not provided when the usual staff member was on leave. Interviews with the Wound Care Nurse and the Director of Nursing confirmed that the absence of signatures on the TAR indicated the treatments were not performed on those dates. The facility's policy required wound care to be provided as ordered to promote healing. The lack of documentation and missed treatments were verified by both the Wound Care Nurse and the DON, who acknowledged that the treatments were not completed as required.