Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease, did not receive wound care and dressing changes as ordered by the physician. The resident was admitted with existing pressure ulcers and deep tissue injuries, and the wound care orders were updated several times by consulting specialists, including instructions for daily dressing changes. Despite these orders, the facility continued to provide wound care only on Monday, Wednesday, and Friday for approximately one week, rather than daily as required by the most recent physician orders. The failure to update and implement the correct wound care orders was identified through a review of the Treatment Administration Record (TAR), interviews with nursing staff, and communication with the resident's spouse and outside providers. The wound care nurse was responsible for transcribing new orders to the TAR but did not update the frequency of dressing changes after receiving new instructions from the podiatrist. This oversight was confirmed by both the wound care nurse and the Director of Nursing, who acknowledged that the orders were not correctly changed and implemented for about one week. During this period, the resident's wounds were noted to be worsening, with increased size and depth, as documented by the consulting podiatrist. The resident's spouse raised concerns about the lack of daily dressing changes, which prompted further investigation and ultimately led to the discovery of the error. The facility's policy required that provider orders be reviewed and followed prior to providing wound care, but this was not done in this instance, resulting in the resident not receiving the prescribed daily wound care.