Failure to Provide Ordered Wound Care and Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that a resident with surgical wounds received necessary treatment and services consistent with professional standards of practice. Specifically, the resident did not receive weekly skin assessments during a specified month, and care to the right surgical wound was not provided as ordered by the physician. Documentation showed that the treatment administration record was not initialed as completed on multiple occasions, and there were no weekly skin or pressure ulcer assessments documented until after the resident was admitted to the hospital. The resident, who had a complex medical history including lung cancer, quadriplegia, kidney disease, hepatitis C, cirrhosis, and encephalopathy, was at high risk for pressure ulcers and had multiple unhealed pressure ulcers documented on assessment. Despite care plan interventions requiring weekly wound assessments and monitoring, staff failed to complete these assessments and did not consistently follow physician orders for wound care. Interviews with nursing staff revealed a lack of awareness regarding wound care orders and inconsistent documentation and monitoring of the resident's surgical site. The resident was ultimately admitted to the hospital with an infection of the right below-knee amputation site, presenting with low blood pressure, significant ulcers, and signs of sepsis and osteomyelitis. Hospital records confirmed the presence of infected wounds and critical illness requiring urgent intervention. Facility policy required weekly skin assessments and timely documentation, but these were not followed, as confirmed by staff interviews and record reviews.