Failure to Follow Physician Orders and Inadequate Wound Care Documentation
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for two residents, resulting in multiple deficiencies. For one resident with complex medical conditions including peripheral vascular disease, renal failure, and recent abdominal surgery, staff did not implement or document physician-ordered treatments as prescribed. Orders for wound care, medication administration, and dietary management were not consistently followed. For example, wound dressings were not changed as frequently as ordered, and medications such as potassium chloride and ferrous sulfate were not administered according to the prescribed schedule. Additionally, significant weight loss was not communicated to the physician, and there was no documentation of the resident's refusal to participate in therapy or the absence of bowel movements. Wound assessments for the same resident were incomplete, lacking essential details such as wound measurements, tissue condition, drainage, and signs of infection. The clinical record did not contain accurate or sufficient documentation of wound status or physician notification regarding the resident's deteriorating condition. During a physician visit, it was noted that all dressings were dated several days prior and had not been changed as ordered, and the resident reported not having a bowel movement for several days. The resident was subsequently hospitalized for failure to thrive, poor wound healing, and weight loss. For another resident with a history of cancer and surgical wound infection, staff failed to follow wound care orders by not using the prescribed wound cleanser and documenting wound care as completed when it had not been performed. Observations revealed wound drainage on the resident's clothing and that wound care supplies were available but not used as ordered. Staff interviews confirmed that wound care was not always provided according to physician instructions, and documentation practices did not accurately reflect the care delivered.