Failure to Provide Physician-Ordered Wound Care Treatments
Penalty
Summary
Facility staff failed to provide wound care treatment as prescribed by physicians for two residents reviewed during a complaint survey. For one resident with a history of systemic lupus erythematosus and venous thrombosis, the medical record showed a venous wound on the left calf with several changes in the treatment plan over time. Despite updated physician orders, the treatment administration record (TAR) indicated that wound care was only provided up to a certain date, with no documentation or explanation for the gap in care before the resident was sent to the hospital. Facility leadership confirmed that the treatment change was not carried out by the nursing staff. For another resident with polyneuropathies, chronic pain, and type 2 diabetes mellitus, the medical record documented a diabetic wound on the right first toe. The TAR showed two overlapping physician orders for wound care, with nurses signing off daily for both treatments. However, the Assistant Director of Nursing confirmed that the treatments were not performed correctly, as the first order was not discontinued when the second was entered, making it unclear whether both treatments were actually provided or if the documentation was inaccurate.