Failure to Follow Wound Care Orders and Complete Weekly Skin Assessments
Penalty
Summary
Facility staff failed to follow prescribed wound care orders for one resident with right lower extremity stasis ulcers. The treatment administration record specified cleansing the wound with Vashe-moistened gauze, applying a dime-thick layer of triad paste, and covering with Exufiber AG dressing, ABD pads, and kerlix, with no tape on the skin. However, during an observation, a registered nurse used a calcium alginate AG dressing instead of the ordered Exufiber AG. The nurse stated that the two dressings were the same, but the facility did not have an order for an equivalent dressing until after the discrepancy was identified. The Director of Nursing confirmed that Exufiber AG was not being used as ordered and that an alternative was not ordered until after the issue was discovered. Additionally, the facility failed to conduct weekly skin evaluations as required for another resident. Review of records showed that weekly skin and wound observations were missed or conducted late, with one scheduled assessment not completed and another performed several days late. The Director of Nursing confirmed that weekly skin and wound observations are to be completed for all residents, regardless of the presence of pressure ulcers, and acknowledged the missed assessments. Facility policy requires comprehensive skin assessments on admission, with each risk assessment, as indicated, and prior to discharge.