Failure to Implement and Monitor Wound Care Results in Harm
Penalty
Summary
The facility failed to implement and monitor wound care treatment as ordered for a resident with multiple non-pressure wounds on the lower extremities. The resident, who was cognitively intact and had a history of congestive heart failure, hypertension, renal insufficiency, benign prostatic hyperplasia, and encephalopathy, developed several stage 2 non-pressure ulcers on both legs and toes. Despite physician orders for specific wound care treatments, documentation showed inconsistent and incomplete implementation of these treatments, with missed dressing changes and lack of evidence for as-needed care or refusals. Wound assessments and measurements were not consistently performed or documented, and new wounds were not always identified or measured in the medical record. Wound photographs and medical record reviews revealed that the resident's wounds worsened over time, with increased size, drainage, discoloration, and additional open areas developing. The treatment administration record indicated that wound care was not performed on certain dates, and some treatments were carried out by staff not qualified to assess or measure wounds. Interviews with staff confirmed that wound care was not always documented, and there was no oversight of the wound care program within the facility. The infection preventionist acknowledged the lack of monitoring and documentation for wound care and as-needed dressing changes. The resident was eventually transferred to the hospital in poor condition, with saturated dressings and wounds covered in feces. Hospital records documented that the resident had extensive wounds with sloughed skin, erythema, and signs of infection, leading to a diagnosis of sepsis and cellulitis likely secondary to the lower extremity wounds. The facility's failure to provide consistent wound care and monitoring, as well as the lack of oversight and documentation, resulted in actual harm to the resident.