Failure to Provide Timely Wound Care for Resident
Penalty
Summary
A resident with a history of paraplegia, chronic respiratory failure, osteomyelitis, and major depressive disorder was admitted and later readmitted to the facility. The resident developed a vascular wound on the rear left calf, which was first identified during a skin assessment. Despite the care plan indicating that wound treatments should be provided per physician orders, there was no evidence that any wound care was initiated or ordered for three days following the identification of the wound. Medical records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), confirmed that no wound care was provided during this period. Subsequently, the resident experienced a significant change in condition, including tachycardia and hypotension, leading to transfer to the emergency room. Hospital documentation noted the presence of the left lower extremity wound with cellulitis, as well as additional pressure injuries acquired during hospitalization. Facility staff interviews confirmed that no wound care orders were placed or treatments completed for the wound during the initial three-day period. The facility's policy required necessary care and treatment to prevent and manage pressure injuries, which was not followed in this instance.