Failure to Complete Ordered Wound Care and Dressing Changes
Penalty
Summary
A deficiency occurred when the facility failed to provide ordered treatments for the care of a resident's cervical spine incision and Jackson Pratt (JP) drain site. The resident, who was admitted with multiple complex diagnoses including infection, spinal fusion, heart disease, and other chronic conditions, had clear after-visit instructions and physician orders for daily wound assessment and dressing changes. These orders included checking the cervical spine incision for redness or drainage, keeping the wound covered with a Medipore island dressing to be changed daily, and cleaning around the JP drain exit site daily. The treatment administration records reflected these orders, with instructions to cleanse the incision and JP drain site with normal saline, pat dry, and apply appropriate dressings daily. Despite these documented orders, the treatments were not completed during the resident's entire stay at the facility. The resident was admitted and discharged within a three-day period, and during this time, there was no evidence that the required wound care and dressing changes were performed. An LPN confirmed in an interview that the orders should have been in place and completed upon admission but were not, and could not provide a reason for the omission. This failure was identified during a complaint investigation and represented continued non-compliance from a previous survey.