Failure to Administer and Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered in accordance with provider orders for a resident with multiple chronic conditions, including Diabetes Mellitus II and Peripheral Vascular Disease. The resident had documented skin impairments, including open areas on the lower extremity, buttocks, and right heel, with care plan interventions specifying that wound care treatments be provided as ordered. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that the resident did not receive prescribed wound care treatments on several specific dates. There was no documentation on the MAR/TAR or in the resident's progress notes explaining why the treatments were missed, except for one instance where wound care was provided by an outside provider but not recorded appropriately. Facility policy required that medications and treatments be administered according to prescriber orders and documented immediately after administration. The interim Director of Nursing confirmed that the expectation was for nurses to follow provider orders for medications and treatments. The lack of administration and documentation for the resident's wound care treatments constituted a medication and/or treatment error, as the facility did not follow its own policy or provider orders, and failed to document reasons for missed treatments.