Failure to Provide Physician-Ordered Wound Care Treatment
Penalty
Summary
A deficiency occurred when a resident with a non-pressure chronic ulcer on the left foot did not receive wound care treatment as ordered by the physician. The resident's care plan identified multiple risk factors for skin breakdown, including peripheral vascular disease, diabetes, and mobility issues, and required daily cleansing and dressing of the affected toe. Despite these orders, the resident did not receive the prescribed wound care over a weekend, as confirmed by both the resident and the wound nurse. The Treatment Administration Record indicated that the treatment was documented as completed, but interviews revealed that the bandage had not been changed since the previous dressing by the wound nurse. The nurse assigned to the resident during the missed days acknowledged that the treatment was accidentally overlooked and not performed. The wound nurse and the DON were made aware of the missed treatments after discovering the unchanged bandage. The resident remained alert and oriented and was able to report the lapse in care. The facility's documentation and staff interviews confirmed that the physician's orders for wound care were not followed as required.