Failure to Update and Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders for a resident with a right above-the-knee amputation (RAKA) were accurate and completed as ordered. The resident, who was cognitively intact and required assistance with activities of daily living, had a history of disruption of wound healing, infection following procedure, dehiscence of amputated stump, gangrene, acidosis, and peripheral vascular disease. Physician orders initially directed that Betadine be applied to the surgical incision and wrapped with fluff gauze once daily. However, after a follow-up with a vascular surgeon, the wound care order was changed to Betadine application twice daily. This updated order was communicated to the facility but was not reflected in the resident's medical record or implemented in practice. Documentation and observation revealed that wound care was only being performed once daily, and on at least one occasion, the dressing was not changed as documented. Staff interviews confirmed that the wound care orders had not been updated in the system to reflect the new instructions from the vascular surgeon, and the facility's policy required treatments to be provided in accordance with physician orders. The inaccuracy in the medical record and failure to follow the most current wound care orders resulted in the deficiency.