Failure to Discontinue Wound Care and Complete Neurological Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident, after sustaining a fall, the medical record and incident report indicated that neurological assessments were to be completed per policy; however, the facility was unable to provide documentation of these neurological checks when requested, and the DON confirmed the assessments could not be located. For another resident, wound care orders for an abrasion to the left gluteus remained active and were carried out ten additional times after the wound had resolved, as the order was not discontinued when the wound healed. This was confirmed by both the RN responsible and the DON, who acknowledged the treatment should have ended when the wound was resolved.