Failure to Complete and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure completion of physician-ordered wound care treatments for a resident with multiple pressure ulcers. Medical record review showed that the resident, who was cognitively impaired and fully dependent for all activities of daily living, had several physician orders for wound care to various areas including the left and right buttocks, right gluteal fold, right heel, left posterior upper thigh, and sacrum. These orders specified cleansing, application of hydrogel and calcium alginate, use of border foam or gauze dressings, and offloading with a heel boot, to be performed every shift or daily as indicated. However, the treatment administration record (TAR) revealed that documentation of these treatments was missing on multiple dates, and there was no evidence that the treatments were completed as ordered. Staff interview with the DON confirmed the absence of documentation and completion of the required wound care treatments on the specified dates. Additionally, facility policy required detailed documentation of wound care, including the type of care given, date and time, resident positioning, assessment data, and staff performing the care, none of which was present for the missed dates. This deficiency was identified during the investigation of two complaint numbers and affected one resident reviewed for pressure ulcers.