Failure to Administer Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to implement physician-ordered wound treatments for three out of five sampled residents. For one resident with diabetes and kidney disease, staff did not provide the prescribed daily wound care for a pressure sore on the right toe on three specific dates, as evidenced by missing documentation in the Treatment Administration Record (TAR). Another resident with hemiplegia, hemiparesis, and hypertension did not receive the ordered application of amlactin lotion to the left toes and foot on multiple dates, as indicated by gaps in the TAR. A third resident with heart failure and atrial fibrillation did not receive the required wound care for a spinal pressure sore on two occasions, with no evidence of treatment recorded in the TAR. These deficiencies were confirmed through clinical record review and staff interview, which established that the wound treatments ordered by physicians were not consistently administered or documented. The administrator acknowledged the lack of evidence that the residents received the prescribed wound care on the specified dates.