Failure to Complete and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that dressing changes for a resident with multiple wounds were completed as ordered by the physician. The resident, who had diagnoses including mild cognitive impairment, diabetes, paraplegia, chronic kidney disease, and both an unstageable pressure injury and a deep tissue injury, had specific physician orders for wound care to the left heel and right buttock. These orders required dressing changes every shift and as needed. Review of the Treatment Administration Record (TAR) and progress notes for two consecutive days showed no documentation that the dressing changes were completed or refused. The resident reported that wound care was not offered or provided during night shifts on those dates, and there was no evidence of refusal. Interviews with the DON and the LPN assigned to the resident confirmed that if treatments were completed or refused, they should have been documented on the TAR, with refusals also requiring a progress note and notification to the wound nurse and physician. The facility's policy required detailed documentation of dressing changes, including date, time, type of care provided, and any refusals. The lack of documentation and failure to provide or record the required wound care constituted non-compliance with physician orders and facility policy.