Failure to Follow Wound Care Protocols and Repositioning Requirements
Penalty
Summary
The facility failed to follow its wound prevention, maintenance, and wound care policies and procedures for three residents. For one resident with quadriplegia, diabetes, and muscle weakness, wound care was provided without a physician's order, despite facility policy requiring such an order. The resident was admitted with no documented open wounds, but a dressing was changed by a nurse without an order, and the nurse stated that no order was needed. The Director of Nursing later confirmed that a physician's order was required and not present at the time of the dressing change. Skin assessments for this resident were inconsistent and did not accurately reflect the condition or location of the wound. Documentation was found to be copied and pasted across multiple assessments, and the wound was not properly staged or described. When an open area was identified, it was not documented as a change of condition, and the required change of condition documentation was not completed. The discharge summary also failed to include a review or assessment of a newly diagnosed stage 4 pressure ulcer or the treatment plan initiated by the wound physician. Additionally, the facility did not ensure that three residents, all with significant mobility impairments and pressure wounds, were repositioned every two hours as required by policy and physician orders. Instead, documentation showed that repositioning was only recorded once per shift. Interviews with staff and residents confirmed that repositioning was not performed or documented every two hours, and residents reported not being offered repositioning as frequently as required.