Failure to Provide and Document Wound Care and Provider Notification
Penalty
Summary
The facility failed to properly assess, monitor, and provide wound care treatments as ordered, and did not notify the appropriate provider when maggots were found in the wound of a resident with paraplegia and multiple pressure ulcers. The resident, who was cognitively intact and used a wheelchair, had a documented history of pressure ulcers and required specialized wound management. On one occasion, an LPN discovered maggots in the resident's foot wound during a dressing change, removed them, and applied hydrogen peroxide, but did not send the resident to the hospital or notify the wound nurse practitioner. The resident reported experiencing maggots in her wounds on two separate occasions and expressed distress over the incident, stating that the LPN did not perform the dressing change correctly. The wound nurse practitioner confirmed she was not informed of the maggot incident and stated that the standard procedure would be to remove the maggots and send the resident to the hospital. Additionally, another resident with quadriplegia and multiple pressure ulcers did not consistently receive wound care treatments as ordered by the physician. Documentation in the Treatment Administration Record (TAR) showed multiple dates where prescribed wound care was not completed for several pressure ulcers, despite clear physician orders and care plan interventions. The Director of Nursing confirmed that wound treatments should be administered and documented as ordered, in accordance with the facility's wound care policy.