Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to perform wound treatments as ordered by the physician for three out of five residents reviewed for wound care. Record reviews and staff interviews revealed that multiple wound care orders were not completed as prescribed for these residents. Specific missed treatments included failure to cleanse and dress various wounds, such as skin tears, pressure ulcers, diabetic ulcers, and venous wounds, on several occasions. Orders for specific wound care products and procedures, such as hydrating foam cleanser, Sureprep, MediHoney, Vashe soaked gauze, calcium alginate, and negative pressure wound therapy, were not carried out according to the prescribed schedule. These deficiencies were confirmed through review of the Treatment Administration Records (TAR) for the affected residents and corroborated by staff interviews, including confirmation from the Corporate Resource Nurse. The missed treatments spanned multiple dates and shifts, affecting residents with complex wound care needs, including those with pressure ulcers, diabetic ulcers, and wounds requiring specialized dressings and monitoring. The lack of adherence to physician orders for wound care was consistently documented across the reviewed cases.