Failure to Consistently Provide and Document Wound Care as Ordered
Penalty
Summary
Facility staff failed to provide wound care as ordered for one resident with a chronic arterial ulcer that later became a pressure ulcer. Review of the treatment administration records (TAR) over several months revealed multiple missed or undocumented wound care treatments, including specific dates in June 2024, March 2025, and May 2025 where wound care orders were not signed off or completed as scheduled. The resident reported having to seek out staff to have dressings changed and described a history of the wound extending from the heel up the leg, though it had since improved. The resident also stated that a former wound nurse refused to provide care, and the Director of Nursing (DON) confirmed the wound's progression and noted the resident's tendency to leave the facility, which sometimes interfered with scheduled care. The DON acknowledged that on some days when wound care was missed, the resident was out of the facility, but also agreed that care should have been documented as provided on a PRN basis or in the notes if completed at a different time. The lack of documentation and missed treatments were not explained by any further information prior to the survey exit conference. The deficiency centers on the failure to consistently provide and document wound care as ordered for a resident with a significant wound history.