Failure to Complete Wound Care Treatments and Follow-Up Appointments as Ordered
Penalty
Summary
The facility failed to ensure that wound care treatments and follow-up appointments were completed as ordered for three residents. For one resident with a history of atherosclerotic heart disease and an open chest lesion, daily wound care orders were not carried out on multiple specified dates, despite the resident being cognitively intact and not refusing care. Another resident with a non-pressure chronic ulcer of the right heel and midfoot did not receive daily wound care as ordered on several dates, and a change in wound care orders was also not implemented on the day it was prescribed. In both cases, the treatment administration records (TARs) confirmed the missed treatments, and the DON verified these omissions during interviews. A third resident, admitted with cerebral palsy, lymphedema, and cellulitis, had orders for Unna boots to be changed three times weekly, but these were not completed on two scheduled days. Additionally, this resident missed a scheduled wound clinic follow-up appointment, which was not documented in the electronic health record, and the resident was not transported to the appointment. Interviews with facility staff and wound clinic personnel confirmed these lapses. The facility's wound management policy required the promotion of treatment and healing of skin integrity impairments, but the documented failures show that wound care and follow-up were not consistently provided as ordered.