Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to assess, document, and provide physician-ordered wound care treatments for six residents with wounds, as required by facility policy. The policy specified that residents with skin impairments should have their wound status assessed and documented in the electronic medical record by a Registered Nurse, and that physician wound progress notes should be used in addition to in-house RN assessments for those followed by wound care physicians. However, clinical record reviews revealed multiple instances where wound care treatments were not documented as completed on the Treatment Administration Record (TAR) for several residents, and there was a lack of evidence that weekly skin assessments were performed as required. For example, one resident with multiple sclerosis and a stage four sacral pressure ulcer had several days where ordered wound treatments were not documented as completed. Another resident with end stage renal disease and a stage four sacral pressure ulcer reported that wound care was not provided regularly, and there was no evidence of wound care being completed for nearly two weeks. Additional residents with conditions such as lymphedema, cellulitis, metabolic encephalopathy, and osteomyelitis also had missing documentation for wound care treatments and assessments, with some lacking any evidence of RN wound evaluation per policy. Interviews with staff, including the Infection Preventionist, confirmed that there was no documented evidence that wound treatments and weekly skin assessments were completed as ordered for the affected residents. The lack of documentation and failure to follow physician orders and facility policy led to the deficiency cited under 28 Pa Code 211.12 (d)(1)(5) Nursing services.