Failure to Document and Obtain Orders for New Wounds
Penalty
Summary
Facility staff failed to meet professional standards of care by not documenting assessments of new wounds and not obtaining timely treatment orders from a physician for a resident with multiple pre-existing wounds. The resident, who had severe cognitive impairment, was at risk for pressure ulcers, had one or more unhealed pressure ulcers, and was receiving hospice care. The facility's policies required specific physician orders for wound treatments and mandated that nurses provide treatment as ordered and implement preventive measures. On review, staff documented the presence of new wounds, including a deep tissue injury to the left medial knee and a scabbed area on the right lower leg, but did not document a full assessment or obtain physician orders for these new wounds. The Physician's Order Sheet and Treatment Administration Record for the relevant period did not contain documentation of wound treatment orders or evidence that treatments were provided for the new wounds. Progress notes also lacked documentation of assessment or interventions for these wounds. Interviews with staff revealed that while some interventions were performed, such as applying skin prep and instructing aides to float the resident's heels, these actions were not properly documented. The DON acknowledged that assessments and documentation were incomplete, and the physician confirmed that staff should have assessed and obtained treatment orders for new wounds. The lack of documentation and failure to obtain timely orders constituted a deficiency in meeting professional standards of care for wound management.