Failure to Provide Physician-Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide necessary wound care treatments as ordered by physicians for three residents with documented skin impairments. For one resident with dementia and chronic kidney disease, physician orders required Medihoney and calcium alginate dressings to be applied every eight hours. However, the treatment administration record (TAR) was signed as completed for several shifts, but direct observation revealed the dressing had not been changed as indicated, with the dressing still dated from a previous shift. The unit manager confirmed the discrepancy between the TAR and the actual dressing date. Another resident with diabetes and a diabetic foot ulcer had physician orders for specific wound care, but the TAR was left blank on two occasions, indicating the treatment was not provided. A third resident with multiple sclerosis and impaired mobility had orders for calcium alginate dressings to be changed twice daily, but observation and TAR review showed the dressing was not changed as required, despite the TAR being signed. The director of nursing confirmed that signing the TAR should indicate the treatment was completed. Facility policy required wound treatments to be provided per physician orders, but this was not followed for these residents.