Failure to Provide Wound Care per Physician Orders and Document Dressing Changes
Penalty
Summary
The facility failed to provide wound care according to physician's orders and did not ensure wound dressings were initialed and dated as required by facility policy. Multiple residents were affected, with one resident not having any of the prescribed wound dressings in place for three pressure ulcers, and several other residents observed with wound dressings that were not initialed or dated. Staff interviews confirmed that wound care was not consistently performed as ordered, and that there was a lack of awareness among nursing staff regarding the status of wound dressings. Resident records revealed that one resident with multiple sclerosis, severe protein calorie malnutrition, and a history of pressure ulcers was at very high risk for skin breakdown. This resident was dependent on staff for hygiene and positioning and had multiple stage three and four pressure ulcers. Despite clear physician orders for specific wound care regimens and dressing changes, observations showed that dressings were missing or not applied as ordered, and staff were unaware of the lapses in care. Additional observations of other residents found wound dressings that were not initialed or dated, with some dressings falling off or not changed as needed. Resident interviews indicated uncertainty about when dressings were last changed, and staff interviews confirmed that required documentation and dressing changes were not consistently performed. Review of facility policy confirmed the expectation to follow physician orders and to mark dressings with initials and dates, which was not adhered to in these cases.