Failure to Complete Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that wound care treatments were completed as ordered for two residents with stage 4 pressure injuries. For one resident with paraplegia and a stage 4 pressure injury on the right upper leg, wound care orders required daily treatment, but documentation showed that treatments were missed on five occasions over a one-month period. The resident confirmed that there had been several instances in the past month when her wound care was not completed as ordered. This resident was cognitively intact, as indicated by a BIMS score of 15. Another resident with metastatic pelvic disease and a stage 4 pressure injury of the coccygeal region had wound care orders for treatment twice daily. Review of treatment flow sheets revealed that the required wound care was not documented as completed on nine occasions within the same timeframe. Interviews with the ADON and DON confirmed awareness of issues with wound care treatments not being completed, though the DON was not aware of the full extent of the problem and could not provide a reason for the missed treatments.