Failure to Follow Wound Care Orders and Document Resident Refusals
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including severe cognitive impairment, diabetes, and arterial ulceration of the right foot, did not receive wound care in accordance with physician orders. The resident's care plan required arterial ulcer dressing changes twice daily and as needed, but documentation showed the dressing was not changed as ordered on several occasions. During an observation, the wound dressing was found to be dated two days prior, indicating it had not been changed per the prescribed schedule. Further review of the medical record and interviews with nursing staff revealed that the resident had refused dressing changes on multiple shifts, but these refusals were not documented in the progress notes as required. Nursing staff admitted to incorrectly marking the treatment as completed on the Treatment Administration Record (TAR) and failing to document the refusal or notify the physician. The Director of Nursing confirmed that the expectation was to attempt the treatment again, document the refusal, and inform the physician if the treatment was not completed. The facility's policies required accurate documentation of wound treatments, including resident refusals and physician notifications. However, there was no evidence that the physician was notified of the missed treatments, and the medical record did not reflect the refusals or the lack of wound care. The physician confirmed not being informed of the refusals and emphasized the importance of notification for continuity of care.