Failure to Provide Physician-Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide physician-ordered wound care treatments for four out of five residents reviewed. For one resident, a daily treatment for a Stage 3 right heel wound was not documented as completed on two specific dates. Another resident with orders for wound care to the left lateral foot and multiple venous ulcers did not have documentation of the required treatment on a scheduled date. A third resident with an order for negative pressure wound therapy did not have evidence of the treatment being performed as ordered on a scheduled day. For a fourth resident, daily treatment for a pressure ulcer on the coccyx was not documented on multiple dates, and negative pressure wound therapy for a left hip wound was also not completed as ordered on several occasions. Nursing notes indicated that, in at least one instance, the lack of treatment was related to a delay in supply delivery for a specific negative pressure wound therapy machine, as reported by the DON. There was no documentation to indicate that the treatments were completed, refused by the residents, or that the residents were unavailable for treatment on the missed dates. The findings were confirmed with the DON and Nursing Home Administrator, and no additional information was provided to account for the missed treatments.