Lack of Physician Oversight for Wound Care
Penalty
Summary
The facility failed to ensure adequate physician oversight for wound care in two residents, resulting in incomplete and non-comprehensive care. For one resident with a history of traumatic brain injury and severe cognitive impairment, weekly skin assessments documented a worsening, facility-acquired unstageable pressure ulcer over several weeks. Despite multiple physician notes during this period, there was no mention of the pressure ulcer, no assessment of its avoidability, and no documented treatment plan. One physician note incorrectly stated that the resident had no current wounds, despite clear evidence to the contrary in the clinical record. For another resident with Alzheimer's disease and muscle weakness, a wound care assessment and consult order were present following readmission, but there was no documentation of physician oversight or notes regarding the resident's wounds. Interviews with facility staff, including the wound care coordinator and DON, revealed that the facility had been without a wound care provider for several months, and that weekly wound rounds were conducted by the wound care coordinator without physician involvement. No documentation of physician oversight or guidance for wound care was provided for this resident.