Failure to Provide Physician-Ordered Daily Wound Care for Non-Pressure Ulcer
Penalty
Summary
A resident with a history of lymphedema, venous insufficiency, and a non-pressure chronic ulcer of the right lower leg was admitted with a right lower extremity wound. The resident's wound care orders were changed by the physician to require daily treatment and as-needed (PRN) care, specifically to wash the right lower extremity, apply calcium alginate, cover with a 2x2 dressing, and wrap with an ace bandage. However, the facility failed to recognize and implement the scheduled daily treatment portion of the order, only documenting the PRN aspect. As a result, from the date of the new order until the wound was identified as healed, there was no evidence that the daily wound care was provided. Review of the treatment administration record (TAR) showed that the daily treatment was not scheduled or documented as completed, and there were no checks or initials indicating the treatment was provided, either daily or PRN, during this period. The Director of Nursing was unable to provide any explanation for the lack of scheduled and administered wound care according to the physician's orders. This failure resulted in the resident not receiving treatment and care in accordance with professional standards of practice for a non-pressure wound.