Failure to Document and Provide Wound Care per Standards
Penalty
Summary
A deficiency was identified when a resident experienced the presence of maggots in their wound on two separate occasions during their stay. The first incident occurred about a week after the resident's admission, and the second incident happened the week prior to the survey. The resident reported both occurrences to nursing staff, including a nurse and the unit manager. Despite these reports, there was no documentation in the resident's medical record or progress notes regarding the presence of maggots or the incidents themselves. The facility's Unit Manager and DON both acknowledged awareness of the situation but were unable to provide any documentation or explanation for the lack of records. Further review of the resident's treatment orders showed that daily and PRN dressing changes were required, with instructions to date and time each dressing. However, during a wound dressing change observed by the surveyor, the dressing was found to have last been changed three days prior, contrary to the documented daily changes on the Treatment Administration Record. The nurse present did not respond when this discrepancy was pointed out, and the ADON later acknowledged understanding of the issue. The lack of documentation and failure to follow wound care protocols led to the identified deficiency.