Failure to Administer and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for two residents who were being treated for pressure ulcers. For both individuals, physician orders for wound care were not followed on multiple consecutive days, as documented in the Treatment Administration Records (TARs). Specifically, wound care treatments ordered by the physician were not administered on four separate days for each resident, and these omissions were not documented or explained in the medical records. One resident, a male with diagnoses including acute congestive heart failure, obesity, asthma, and edema, was assessed as being at risk for pressure ulcers and had specific wound care orders in place. Despite these orders, the TARs showed that the prescribed wound care was not provided on several days. Similarly, a female resident with chronic obstructive pulmonary disease, muscle weakness, end-stage renal disease, hypertension, and a pressure ulcer also did not receive the ordered wound care on the same dates. Observations confirmed that, at the time of survey, there was no infection or worsening of wounds, but the required treatments had not been administered as ordered. Interviews with facility staff revealed confusion and lack of communication regarding responsibility for wound care, particularly in the absence of the wound nurse (WN). Nurses on duty sometimes assumed the WN would provide the care, resulting in missed treatments. The Assistant Director of Nursing (ADON) and other staff acknowledged the importance of adhering to physician orders and confirmed that the omissions occurred. Facility policies required documentation of all wound care provided, but the records did not reflect that the treatments were given as ordered.