Failure to Monitor and Implement Wound Care Interventions
Penalty
Summary
A resident with multiple complex medical conditions, including hemiplegia, diabetes mellitus with a foot ulcer, and severe cognitive impairment, was not properly monitored or treated for a diabetic foot ulcer. The care plan required the application of protective boots, floating of legs with pillows, and ongoing monitoring and documentation of the wound's size, depth, margins, and healing progress. However, medical record review showed that weekly wound assessments were incomplete, often missing measurements and detailed descriptions of the wound bed. Additionally, hospice notes provided to the facility lacked detailed weekly wound documentation, and the DON confirmed she had not reviewed these reports, which misidentified the wound as a stage two pressure ulcer. Observation revealed the resident was found in bed without the required protective boots, and their heels and legs were directly on the mattress, contrary to care plan interventions. Staff interviews confirmed inconsistent understanding and implementation of the boot application schedule. Facility policy required comprehensive wound documentation with each dressing change or at least weekly, but this was not followed, resulting in a failure to monitor the resident's wound and implement necessary interventions as outlined in the care plan and facility policy.