Failure to Complete Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that wound care treatments were completed as ordered for one of three residents reviewed for wound and skin care. Specifically, a resident with diabetic venous ulcers and other comorbidities had physician orders for dressing changes to a left lower leg ulcer to be performed twice daily. Documentation revealed that the second daily dressing change was not completed or documented thirty-five times over a period of just over a month. Observations and interviews confirmed that the resident often did not receive dressing changes at night and sometimes during the day, and that the dressing was found saturated and soiled, with drainage noted on the resident's pillowcase. The treatment nurse confirmed the missed treatments and acknowledged that wound care was not consistently performed as ordered, especially during night shifts and weekends when the treatment nurse was not present. The resident's wound was documented as worsening, with a significant increase in size over a two-month period. The treatment nurse and Assistant DON both confirmed that failure to complete wound care as ordered could lead to worsening wounds. The DON was aware of concerns regarding incomplete treatments but was not aware of the extent of the issue. The resident was cognitively intact and had a history of chronic kidney disease and lower extremity edema, with a medical note indicating that vascular surgery was not recommended and that an above-the-knee amputation would eventually be required.