Failure to Reevaluate Wounds at End of Treatment Orders
Penalty
Summary
The facility failed to reevaluate wounds for a resident when treatment orders were ending. According to progress notes, the resident returned from a hospital appointment with a bleeding left second toe, where the nail was not intact, and a skin tear on the left lateral foot. Orders were given to cleanse and treat both wounds with bacitracin every shift, monitor for infection and worsening for 14 days, and follow up with a wound doctor. The Treatment Administration Record showed that the last day of treatment and monitoring for these wounds was on 7/6/25 during the day shift. Interviews with the treatment nurse and the Director of Nursing confirmed that wounds should have been reevaluated at the end of the treatment period, with documentation in the progress notes indicating whether treatment should continue or be discontinued. However, neither staff member could provide documentation that the wounds were reevaluated at the end of the treatment period. Additionally, the facility was unable to provide a policy regarding wound reevaluation at the end of treatment orders.