Failure to Provide Timely and Appropriate Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services to promote healing and prevent the worsening of non-pressure related wounds for three residents. One resident with a history of left total knee arthroplasty experienced ongoing pain, redness, and swelling in the left knee and lower leg. Despite repeated recommendations from wound care and medical staff for an MRI and orthopedic consult, the facility did not ensure these were completed. The MRI was canceled multiple times due to insurance concerns, and no further assistance was provided to obtain the imaging or consult. The resident received multiple courses of oral antibiotics without resolution, and a subsequent course of antibiotics was not administered as ordered. The resident was eventually hospitalized with a septic joint, underwent surgical intervention, and returned to the facility with ongoing pain and loss of function. Another resident with a history of basal cell carcinoma removal and multiple sclerosis developed a wound on the right lower extremity. An initial treatment order was entered and discontinued on the same day, and no new order was entered, resulting in a lack of assessment or treatment for nearly two weeks. During this period, the wound deteriorated and increased in size. The wound was only reassessed and treated after the resident requested to see the wound clinic, at which point antibiotics and appropriate wound care were initiated. A third resident with multiple comorbidities, including sepsis and systemic sclerosis, received wound care treatments that were not supported by physician orders. Staff applied lidocaine, gentian violet, and Iodosorb to wounds without corresponding medical orders, and substituted treatments when supplies were unavailable without documented physician approval. These actions were observed during wound care and confirmed by staff interviews, indicating a lack of adherence to established protocols for wound management and physician-directed care.
Removal Plan
- Identify other residents with current wounds and assess for signs/symptoms of infection, including redness, warmth, pain and swelling, and ensure referrals, consults, imaging, lab work, antibiotics, and wound treatments are administered.
- Educate licensed nursing staff on the facility's wound management policy and protocol to follow-up on skin issues as well as updating/documenting dressing changes.
- Review all wound orders by the DON/designee to ensure accuracy and follow-up.
- Conduct skin audits. Provide education when indicated.