Failure to Complete Physician-Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the physician for a resident with a diabetic foot ulcer. The resident, who had moderate cognitive impairment and diagnoses including unspecified dementia, coronary artery disease, and diabetes mellitus, had physician orders for daily wound care to the left medial heel. Review of the Treatment Administration Records (TAR) revealed multiple instances where wound care treatments were either not documented as completed or were marked as refused without appropriate supporting documentation. Specific dates were identified where no evidence of treatment was recorded, and in some cases, the dressing on the resident's foot was observed to be outdated, indicating the treatment had not been performed as scheduled. Interviews with staff and the resident's family confirmed that wound care was missed on several occasions, and staff were sometimes unsure of when the last dressing change had occurred. Staff also acknowledged that if treatments were not signed out, it may indicate they were not done or not properly documented. Facility policy required that all administered treatments be recorded, and any refusals or missed treatments be documented with appropriate codes and progress notes, which was not consistently followed in this case.