Failure to Provide Timely Wound Care, Medication Administration, and Physician Notification
Penalty
Summary
The facility failed to protect two residents from neglect by not ensuring timely and appropriate medical care and communication with physicians. One resident was admitted with a pressure ulcer but did not have wound care orders or treatment initiated until several days after admission. Documentation shows that the wound was identified upon admission, but no orders for wound care or wound consult were entered until nearly a week later, resulting in a delay in treatment. Interviews with nursing staff and administration confirmed that wound care should have been initiated within 24 hours of admission, and the lack of documentation indicated that the treatment did not occur as required. Another resident with multiple complex medical conditions, including end-stage renal disease, sepsis, and numerous wounds, was admitted without all necessary medication and treatment orders being entered or implemented. This resident did not receive prescribed IV antibiotics (Zosyn) or wound care treatments for several days after admission. Additionally, the facility failed to notify the resident's physician when the resident missed a scheduled hemodialysis session and when wound care orders were not implemented. The resident also did not receive adequate pain management, as only PRN oral acetaminophen was ordered, which was not appropriate for a resident with a gastrostomy tube, and no pain assessments were documented prior to wound care procedures. Interviews with facility staff revealed confusion and lack of clarity regarding roles and responsibilities for wound care and admission processes. There was no evidence of a comprehensive clinical review of new admissions to ensure all necessary orders and treatments were in place. The failures in communication, documentation, and timely implementation of physician orders led to significant lapses in care for both residents, as confirmed by staff interviews and record reviews.