Failure to Obtain Consent for Wound Debridement by Outside Providers
Penalty
Summary
Facility staff failed to ensure that outside providers obtained consent from a resident's representative prior to performing a debridement procedure on a resident's right heel wound. The resident, who had a diagnosis of dementia and was assessed to have moderate cognitive impairment with a BIMS score of 8 out of 15, was admitted following a hospitalization and had a documented deep tissue injury (DTI) on the right heel. The facility's social worker communicated with the resident's assisted living staff and scheduled an assessment of the wound, with the resident's representative aware that an assessment would occur but not informed that a debridement would be performed or that consent would be needed for such a procedure. On the day of the incident, two nurse practitioners from the resident's assisted living arrived at the facility, identified themselves, and were escorted to the resident's room by a nurse. The nurse introduced them to the resident and informed the resident that the providers were there to assess the wound. The nurse then left the room but returned to find the providers performing a debridement without having obtained consent from the resident's representative. The nurse instructed the providers to stop the procedure and reported the incident to facility management. Interviews confirmed that consent was not obtained prior to the debridement.