Failure to Complete and Document Wound Care and Assessments
Penalty
Summary
Staff failed to provide care according to standards of practice for a resident admitted with multiple wounds. Upon admission, the resident had several wounds to both lower extremities, including calluses with black eschar, abrasions, and skin tears, as well as a recent surgical site from a toe amputation. Despite these findings, staff did not obtain or document timely physician orders for wound care, particularly for the skin tears, and did not consistently document wound treatments as required. There were multiple instances where wound treatments were not documented on specific dates, and weekly skin assessments were either incomplete or missing, with some assessments lacking measurements of the wounds. The facility's own policies required licensed nursing staff to initiate admission assessments, update care plans based on identified needs, and carry out physician orders for medication and treatment. However, review of the resident's records showed that treatment orders were delayed, not all wounds were included in the care plan, and documentation of wound care was inconsistent. Interviews with nursing staff and the DON confirmed that there were lapses in completing and documenting wound assessments and treatments, and that the electronic medical record system was not always used as intended to prompt timely assessments and interventions. The resident reported that wound care was not consistently provided, with periods where wounds were not seen or treated by nursing staff. Observations and interviews with staff revealed that not all wounds were measured or assessed as required, and that communication and follow-through on wound care responsibilities were lacking. The facility did not provide a specific wound care policy, and the documentation and care provided did not meet the standards outlined in the facility's general assessment and medication order policies.