Failure to Provide Timely Wound Care, Pain Management, and Assessment
Penalty
Summary
Facility staff failed to provide appropriate wound care and pain management for multiple residents, as evidenced by direct observations, interviews, and record reviews. For one resident with bilateral lower extremity venous ulcers, wound dressings were not dated as required by facility policy, and there was no documentation or evidence that wound care was performed daily as ordered by the physician. Staff interviews confirmed that wound dressings were not dated, and the Treatment Administration Record lacked documentation of wound care on specific days. The Director of Nursing verified that wound care was not completed as required. Another resident with a left heel wound and diabetic foot ulcer did not receive weekly wound assessments as outlined in the care plan. Documentation showed that after a certain date, no further weekly wound assessments were completed, and there were no wound measurements from outside wound care appointments. The Director of Nursing confirmed the lack of weekly wound evaluations, and the facility's wound care policy did not specify the required frequency for wound assessments. A third resident receiving hospice care did not receive pain medication during a painful catheter reinsertion procedure, despite expressing pain and having PRN pain medication available. The hospice nurse did not offer pain medication before or during the procedure, and the resident repeatedly verbalized pain. Additionally, staff failed to address a change in the resident's condition, as deep redness was observed in the peri area, buttocks, and under the breasts, but no treatment orders were obtained or implemented at the time. Staff interviews confirmed these deficiencies in care and communication.