Failure to Follow Wound Care Recommendations and Delayed Treatment Orders
Penalty
Summary
The facility failed to follow wound care practitioner (WCP) treatment recommendations and did not document accurate wound measurements for a resident with significant medical conditions, including peripheral vascular disease, atherosclerotic cardiovascular disease, and cellulitis. After a new wound was identified on the resident's right lower leg, the WCP recommended cleansing the wound with Dakin's solution, applying calcium alginate, and covering with ABD and kling. However, the facility instead ordered and implemented cleansing with normal saline solution (NSS), contrary to the WCP's recommendations. Additionally, subsequent changes in the WCP's treatment recommendations were not reflected in updated physician orders, and the facility continued to use outdated treatments. There were also discrepancies in wound measurements documented by nursing staff and the WCP, with no explanation provided for these inconsistencies. In a separate incident, the same resident developed a skin tear on the left wrist. Although the physician and wound care team were notified and recommendations were made to cleanse the area with NSS and apply a xeroform dressing, no treatment order was entered or implemented for eight days after the wound was identified. The delay in obtaining and implementing a treatment order was confirmed by review of the treatment administration record and interviews with facility staff, who could not provide an explanation for the delay. Facility policies required immediate transcription and implementation of wound care orders, as well as accurate and complete documentation of wound assessments and treatments. Despite these policies, the facility did not ensure timely and accurate execution of wound care recommendations and orders, nor did it maintain consistent and accurate documentation regarding wound measurements and treatments provided.