Failure to Provide Comprehensive and Timely Foot Wound Care
Penalty
Summary
A resident with multiple complex medical conditions, including diabetes, heart failure, and venous insufficiency, was admitted with a wound on the left great toe. Upon admission, there was no comprehensive assessment of the wound's size or characteristics, and no wound assessment was documented from several days after admission until later in the month. The initial hospital order for wound care was not implemented until four days after admission, and subsequent treatment administration records showed multiple missed days where the prescribed wound care was not documented as completed. Additionally, when the wound clinic updated the treatment order, the new order was not initiated promptly, and the previous treatment was not discontinued, resulting in both treatments being administered concurrently for over two weeks. Wound evaluation notes repeatedly lacked documentation of the wound bed assessment, and the peri-wound appearance was consistently described as dry and flaky. Interviews with the resident revealed that wound care was not provided daily as ordered, and the resident reported insufficient staff to administer treatments in a timely manner. The Assistant Director of Nursing confirmed the lack of comprehensive assessment, delays in implementing treatment orders, missed documentation of treatments, and improper handling of updated wound care orders. The facility's wound nurse was absent during this period, and there was no evidence of weekly wound assessments until her return.