Failure to Verify and Provide Wound Vac Care Upon Admission
Penalty
Summary
The facility failed to ensure acceptable nursing standards of practice when a resident was admitted from the hospital with a wound vacuum (wound vac) in place for an open surgical abdominal wound. Upon admission, the facility did not verify or obtain the necessary wound vacuum treatment orders, including dressing change schedules and required supplies, as indicated in the hospital discharge summary. The resident's admission physician order sheet and treatment administration record did not contain any wound care orders for the abdominal wound vac, and the initial nursing assessment did not address the surgical wound or the wound vac. Throughout the resident's stay, there was no documentation of wound care being provided to the abdominal wound vac. Nursing staff, including the DON and LPNs, confirmed that the admitting nurse and subsequent staff did not verify or solicit wound care orders from the hospital or the resident's physician. The resident and family raised concerns about the lack of wound vac changes, noting that in the hospital, the wound vac was changed every 72 hours. Despite these concerns, the facility did not have wound care supplies available, and no orders were located or obtained during the resident's stay. As a result, the resident did not receive any wound care or wound vac changes while at the facility. The deficiency was identified when the resident and family requested discharge to the hospital for wound evaluation and treatment after discovering that no wound care had been provided since admission. Interviews with facility staff confirmed that the required assessments and order verifications were not completed, and the resident's wound care needs were not met during their stay.