Failure to Implement and Document Wound Care and Assessments
Penalty
Summary
The facility failed to ensure that wound care treatment and assessments were appropriately implemented and completed for a resident with a history of Parkinsonism, dementia, and dysphagia, who was assessed to have impaired cognition. Despite the identification of a new blister with green and yellow drainage on the resident's right thigh, and subsequent notification of the physician with orders for laboratory testing and antibiotic therapy, no wound care treatment orders were implemented, and no wound assessments were documented from the time the blister was identified through several months. The care plan indicated the resident was at risk for impaired skin integrity, but there was no evidence of wound care or assessment for the blister during the specified period. Observations revealed the presence of a bandage on the resident's right thigh, and interviews with nursing staff confirmed that although the wound was known and bandages were being changed, formal wound care orders were not followed, and required assessments were not completed or documented. The facility's own policy required physician orders for wound care and thorough documentation of wound care and assessments, but these procedures were not adhered to in this case. The Assistant Director of Nursing confirmed that wound care treatment orders and assessments were not implemented or documented as required.