Failure to Provide Wound Care as Ordered
Penalty
Summary
A deficiency occurred when wound care for a resident with multiple complex medical conditions, including paraplegia, stage IV pressure ulcer, and severe cognitive impairment, was not completed as ordered by the physician. The resident was dependent on staff for all activities of daily living and had orders for daily dressing changes to a right foot wound. Observation revealed that the dressing on the resident's right foot had not been changed for two days, despite physician orders specifying daily changes. The dressing was found to be heavily soiled with drainage and had a foul odor, and the tissue around the wound was white and emaciated. Review of staff assignment sheets and timecards confirmed that the dressing change was last completed by an LPN on one day, and then not again until two days later, missing at least one required dressing change. The facility's wound care policy required dressings to be changed and marked with the date, time, and staff initials. The failure to follow physician orders and facility policy for wound care led to the deficiency cited in the report.