Failure to Provide Comprehensive Wound and Device Care
Penalty
Summary
The facility failed to ensure a comprehensive wound management system was in place for multiple residents, resulting in deficiencies in wound care and treatment according to physician orders. One resident with a recent surgical amputation and moderate cognitive impairment was observed with a dressing on the left lower leg that was not changed as ordered, with documentation indicating the dressing was not current. Another resident with a central venous catheter and intact cognition was discharged with a central line dressing that was not intact and had not been changed as ordered, despite documentation in the facility records indicating otherwise. The home care nurse reported the dressing had not been changed for several weeks, and photographic evidence supported this finding. A third resident with a nephrostomy tube and intact cognition had physician orders for regular dressing changes, but interviews and observations revealed the dressing was not changed as ordered. Staff interviews confirmed that documentation of dressing changes was inaccurate, with nurses signing off on treatments that were not performed. The facility also lacked a policy for nephrostomy tube care, contributing to the inconsistency in treatment. Additionally, a resident with chronic conditions and limited mobility was not provided with timely incontinence care or wound assessments. Observations showed the resident remained in a soiled brief for extended periods, resulting in redness and open areas on the buttocks. Staff interviews confirmed that the resident was not checked or changed as required, and wound care was not performed according to orders. The wound care nurse had not assessed the resident for several weeks, and inappropriate application of wound care products was observed.