Failure to Provide Wound Care and Assess Power Wheelchair Use
Penalty
Summary
The facility failed to provide appropriate wound care and assessment for two residents. One resident was re-admitted with a surgical neck incision that was almost healed and open to air. Documentation showed conflicting information about whether the incision was covered with a dressing, and there were no orders for dressing changes or ongoing wound assessments after readmission. Staff confirmed that wounds, including incisions, should be monitored weekly and that the resident always had a dressing in place due to a neck brace. However, staff did not recall the wound's appearance prior to a significant event where the incision fully dehisced, resulting in bleeding and emergency hospital transport. The Director of Nursing Services (DNS) acknowledged that staff did not obtain wound care orders or assess the incision after readmission. Another resident, admitted with a diagnosis of seizures and dependent on staff for mobility, had their power wheelchair use restricted due to safety concerns. The care plan was revised to prohibit use of the electric wheelchair, but the clinical record lacked a required Power Mobility Device Screen assessment. Staff interviews revealed that the resident sometimes used the power wheelchair for short periods, but no formal assessment was conducted to determine safety or appropriateness. The DNS confirmed that an assessment should have been completed and findings reviewed with the resident.