Failure to Complete Wound Assessments, Treatments, and Ensure Attendance at Medical Appointments
Penalty
Summary
The facility failed to complete weekly wound assessments for a resident with a diabetic ulcer. Medical record review showed that no weekly wound assessments with measurements were completed for the resident during a specific month, despite the presence of an active wound and a care plan that included wound management interventions. The Director of Nursing confirmed the absence of these required assessments during staff interview. Additionally, the facility did not complete wound treatments as ordered for another resident with multiple wounds resulting from frostbite and amputations. Review of the Treatment Administration Records (TAR) and physician orders revealed that wound care was not performed on several occasions for various wounds, including the right hand, left foot, left hand, left hip, and right foot. Documentation was also missing for some of the missed treatments, and the resident reported that wound care was not completed timely, particularly on the night shift. The Assistant Director of Nursing verified that wound care was not completed as ordered by the physician. The facility also failed to ensure that a resident attended a scheduled outside physician appointment. The resident was scheduled for a follow-up with an orthopedic physician but did not attend the appointment. The administrator initially stated that the resident had canceled the appointment, but the resident denied this, and the physician's office confirmed that the resident did not call to cancel. Staff interviews revealed that the facility did not have a policy regarding resident appointments.