Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to complete all physician-ordered wound treatments for one of three residents reviewed during the investigation. Record review and staff interviews revealed that, over a three-month period, multiple wound care orders were not documented as completed on several specific dates. These orders included cleaning and treating various wounds such as a deep tissue injury to the left buttocks, wounds at an amputation site, venous ulcers on the feet and digits, abrasions, a diabetic wound, and stage 2 pressure ulcers to the sacrum. The prescribed treatments involved wound cleansing, application of skin prep, Betadine, sureprep, silicone barrier cream, and appropriate dressings, all to be performed during the day shift. The missing documentation and lack of completion of these wound care orders were confirmed by both the Corporate Resource Nurse and the Administrator. The findings were based on a thorough review of physician orders and Treatment Administration Records (TARs) for the period from August through October, and the facility leadership agreed that the wound treatments were not completed as ordered by the physician.