Failure to Provide Adequate Wound and PICC Line Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents requiring specialized wound and intravenous (IV) care. One resident was admitted with diagnoses including infective endocarditis and a surgical wound on the right foot, requiring daily wound dressing changes and long-term IV antibiotics via a PICC line. Upon review, it was found that the resident did not receive appropriate wound care or PICC line management following admission. The wound dressing applied at the hospital remained unchanged for several days, and the PICC line was observed without a protective cap, increasing the risk of infection. Orders for wound care and PICC line dressing changes were either not entered or entered incorrectly into the facility’s records, resulting in missed treatments and lack of monitoring. Nursing staff failed to document the condition of the wound or the PICC line, and weekly skin assessments did not reflect the resident’s actual needs or current conditions. Another resident with diabetes, dementia, and multiple wounds, including a diabetic ulcer and pressure ulcers, was also not provided with adequate wound care. The resident was observed without dressings on several wounds, and a wound on the bottom of the left foot was not assessed, monitored, or treated by facility staff. This wound was not documented in the facility’s records or skin assessments, despite being noted by an outside nurse from a community day center. The lack of documentation and treatment led to the development of a wound infection, as confirmed by subsequent medical notes and the need for antibiotic therapy. Interviews with facility staff, including the DON and LPNs, revealed a lack of awareness and communication regarding the residents’ wound care needs and PICC line management. Staff relied on incomplete or incorrect documentation, resulting in missed treatments and failure to identify or address new and existing wounds. The facility’s care plans and treatment administration records were not resident-centered and did not include specific interventions or monitoring for the residents’ conditions, directly contributing to the deficiencies in care.