Missed Wound Care Treatments During Staff Absence
Penalty
Summary
A deficiency was identified when a resident with diagnoses including generalized weakness and gait abnormalities did not receive wound care as ordered by the physician. The resident's orders included cleansing the buttocks and groin with a special wound cleanser and applying medicated dressings. Review of the Treatment Administration Report (TAR) for April revealed that on six specific dates, there was no documented evidence that the prescribed wound care was performed. Interviews with the resident, the wound nurse, and the Director of Nursing confirmed that wound care was not completed on these dates, which coincided with the wound nurse being on vacation. The resident reported that when the regular wound nurse was absent, wound care was typically not provided, particularly by agency staff. The absence of documentation and staff confirmation indicated that the required wound care treatments were missed.