Failure to Obtain and Follow Wound Vac Dressing Orders Resulting in Harm
Penalty
Summary
The facility failed to ensure that appropriate wound dressing orders were obtained and followed for a resident with a left below-the-knee amputation and multiple comorbidities, including Parkinson's Disease and peripheral vascular disease. The resident had a negative pressure wound therapy (wound vac) applied to the surgical site, but there were no documented physician orders for wound vac changes between September 9 and September 16. During this period, the wound vac dressing remained in place for ten days without being changed, contrary to standard practice and the facility's own wound management policy, which requires treatment per physician order and regular skin assessments. When staff attempted to change the wound vac dressing, they found the sponge severely adhered to the wound, resulting in significant bleeding and pain for the resident. The lack of documentation regarding dressing changes and absence of a wound nurse contributed to confusion among staff about wound care responsibilities and supply ordering. The incident led to the resident being transferred to the hospital due to excessive bleeding. Interviews with clinical staff and providers confirmed that the dressing was not changed as expected and that there were no clear orders or documentation guiding wound care during the period in question.