Failure to Maintain Wound Dressings for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with wounds received the necessary treatment and services to promote healing and prevent infection. For one male resident with a history of intellectual disabilities, anemia, and hypertension, the care plan and physician orders required a dressing to be applied to a venous or arterial ulcer on his right lateral ankle. On the day of observation, the resident was found without a dressing on the wound, which was open and missing the top layer of skin. The resident reported discomfort without the dressing, and the treatment nurse confirmed that the dressing was missing, possibly due to it falling off during a shower. The nurse acknowledged that staff were responsible for monitoring dressings and that a new dressing should have been applied if it was found missing. A second resident, a female with pressure ulcer of the sacral region, chronic kidney disease, and dysphagia, was also found without a required dressing on her sacral wound. The care plan and physician orders specified the use of a gauze-soaked Dakin's Solution and a dry dressing. During observation, a CNA discovered the wound was uncovered and stated that the nurse should have been notified to apply a new dressing. The treatment nurse and LVN both confirmed that they were not aware the dressing was missing and would have applied a new one if notified. The wound was described as large and uncovered at the time of observation. Interviews with staff, including the treatment nurse, LVN, physician, and DON, confirmed that dressings are essential for wound protection and healing, and that staff are expected to monitor and replace dressings as needed. The facility's policy on wound management also requires wounds to be managed and dressed appropriately to maximize healing. The failure to ensure dressings were present and maintained as ordered led to the deficiency for both residents.