Failure to Follow Wound Care Orders and Maintain Dressing Integrity
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and multiple wounds did not receive wound care in accordance with physician orders and professional standards. The resident, who was dependent for all activities of daily living and cognitively intact, had specific orders for wound care on both feet, including scheduled dressing changes and as-needed care for soilage or dislodgement. Documentation showed that wound care was provided on certain dates, but on a day when the resident was observed, there were no dressings present on either foot, despite orders requiring them. Interviews with staff revealed a lack of awareness and supervision regarding the resident's wound care. The contracted wound care nurses, who worked weekdays, confirmed that dressings should have been in place and could not explain their absence. The RN Supervisor and other nursing staff were unable to account for when or why the dressings were removed or not reapplied, and CNAs were expected to report any issues with dressings to the assigned nurse. However, there was no documentation or staff knowledge of any such report or intervention on the day in question. Facility leadership, including the DON and Administrator, confirmed that the resident should have had dressings in place according to physician orders and acknowledged that the failure to ensure clean, intact, and correctly applied dressings did not meet professional standards of practice. The deficiency was identified through observation, record review, and interviews, which demonstrated a breakdown in communication, supervision, and adherence to wound care protocols for the resident.