Failure to Provide and Document Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care as ordered for one resident who was being treated for pressure ulcers and malnutrition. Observations and record reviews revealed that the resident's wound dressings were not changed according to physician orders, with documentation missing for several days. Specifically, the treatment record lacked entries for wound care on four separate dates, and a wound care provider noted that a bandage had not been changed for six days, which was deemed inappropriate. The resident was observed with dressings dated the current day and did not voice complaints when asked about their wound care. Further review of the medical record confirmed the resident had diagnoses including moderate protein calorie malnutrition and unstageable pressure ulcers. The DON acknowledged that the missed treatments were only discovered after the resident's wound care appointment, and confirmed that nurses are expected to complete and document care as ordered. The deficiency was identified through a combination of observation, interview, and record review, and was cited as past noncompliance after the facility had already implemented corrective actions.