Failure to Provide Ordered Wound Care and Bowel Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs in several instances. For one resident with multiple wounds, including a left hip abrasion and diabetic foot ulcers, the treatment administration record indicated that wound care was to be performed every other day. However, documentation and staff interviews revealed that the dressing change for the left hip/buttock was not completed as ordered, despite being signed off in the treatment record. A nurse was unaware of the wound and only discovered it upon direct observation, confirming that the treatment had not been performed as documented. Additionally, the facility did not initiate bowel interventions for three residents who had not had a bowel movement for several days. Review of medication administration records and bowel movement task sheets showed that PRN bowel medications and assessments were not administered or documented as required after 72 hours without a bowel movement. Staff interviews confirmed that bowel protocols and assessments were not initiated in a timely manner, contrary to facility expectations and residents' care needs.