Failure to Complete Timely Wound Assessments and Implement Physician Orders for Pressure Redistribution Mattress
Penalty
Summary
Two residents did not receive necessary care and treatment as required by their care plans and physician orders. One resident was admitted with a surgical wound to the left foot following toe amputation and had diagnoses including chronic osteomyelitis, diabetes, asthma, dementia, and schizophrenia. Upon both initial admission and readmission, a comprehensive wound assessment was not completed until three days after each event, despite no documentation of the resident refusing assessment on those dates. While the care plan and treatment administration record noted the resident sometimes refused dressing changes, there was no documentation of refusals for the specific dates in question, and the director of nursing confirmed that no additional information was available to explain the delay in assessment. Another resident, who was cognitively intact and had diagnoses including systemic lupus, hypertension, morbid obesity, anxiety disorder, and major depressive disorder, had a physician order for a pressure redistribution (air) mattress due to high risk for skin impairment. Despite this order, the resident was observed in a bariatric bed with a regular mattress and reported never having received the ordered air mattress. Staff interviews confirmed the resident should have been on an air mattress per physician order, but there was no documentation or explanation provided for why the order was not followed. The care plan and care card indicated the resident was at risk for skin integrity issues and required regular repositioning, but the specific physician order for the air mattress was not implemented. Additionally, the facility did not have a policy or procedure in place for physician orders when requested by the surveyor. The lack of timely wound assessments and failure to provide ordered equipment, along with missing documentation of resident refusals and absence of relevant policies, contributed to the deficiencies identified during the survey.