Failure to Provide Timely and Documented Wound Care for Two Residents
Penalty
Summary
Two residents did not receive appropriate care and services to promote healing or prevent the development of pressure injuries. One resident was admitted with pressure injuries on the coccyx and deep tissue injuries (DTIs) on both heels. Upon admission, there were no wound care orders in place, and staff did not change the resident's coccyx and heel dressings for seven days. Wound care orders were not initiated until several days after admission, and even after orders were obtained, dressing changes for the coccyx and heels were missed on multiple documented occasions. The initial skin assessment also lacked measurements of the wounds, and the care plan was not fully implemented as wound care was not consistently provided as ordered. Another resident with wounds on the right great toe, right heel, and coccyx had wound care orders in place, but documentation of wound care completion was missing for one day. The DON confirmed that wound care should have been completed and documented as ordered, but the responsible LPN stated that the care was performed but not documented at the time. The facility's policy requires a head-to-toe evaluation upon admission, prompt notification of the primary care physician, and initiation of appropriate treatment orders, which were not consistently followed for these residents.