Failure to Discontinue Unna Boots and Timely Assess Wounds Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident with a history of lymphedema, morbid obesity, and venous ulcers did not receive wound care in accordance with professional standards, physician orders, and the comprehensive care plan. Upon admission, the resident had multiple wounds, but there was no documented evidence specifying the type, number, or location of these wounds, nor were physician-ordered treatments obtained in a timely manner. The initial wound assessment was incomplete, and there was a lack of documentation regarding wound care orders within the first 24 hours of admission, as required by facility protocol. The resident had physician orders for Unna boots to be applied to both legs, which were later discontinued by physician order. However, documentation and staff interviews revealed that the Unna boots remained in place for seven days after the discontinuation order, without a current physician order and without appropriate monitoring or assessment. During this period, there was no evidence of wound assessments being performed, and the resident's wounds were not evaluated weekly as required. Staff interviews confirmed that the dressings remained in place and were not removed or changed as ordered. On the day the resident complained of severe left leg pain, the Unna boot was removed, revealing a new open wound on the left outer ankle with an infestation of maggots. The resident was subsequently sent to the hospital due to the wound and intractable pain. The facility also lacked a policy addressing non-pressure injury wounds, and staff acknowledged lapses in documentation, assessment, and timely acquisition of physician orders for wound care. These failures resulted in harm to the resident, though the situation was not classified as Immediate Jeopardy.