Failure to Administer Wound Care and Dressing Changes as Ordered
Penalty
Summary
The facility failed to administer wound treatments and perform dressing changes as ordered by the physician for one resident. Clinical record review and observation revealed that the resident had multiple pressure ulcers, including a Stage 3 ulcer on the left ankle, a Stage 1 ulcer, and an unstageable ulcer. The care plan was updated to address wounds on the left inner ankle and coccyx, but did not include information about a wound on the right foot. Physician orders directed staff to cleanse the right lateral foot wound, apply calcium alginate, and cover it with a silicone absorbent dressing daily and as needed. Documentation showed that dressing changes for the right lateral foot were only recorded on specific days, and during observation, the dressing on the right lateral foot was found to be dated several days prior. Staff interviews confirmed that dressings should be dated and initialed each time they are changed, and that the frequency of changes should match physician orders. The Director of Nursing stated that the date and initials on the dressing are used to verify when and by whom the dressing was changed. Policy review indicated that the facility is required to implement treatment orders accurately and in accordance with the resident's care plan. The lack of documentation and failure to perform dressing changes as ordered led to the identified deficiency.