Failure to Provide and Document Required Wound Care and Assessments
Penalty
Summary
The facility failed to ensure that three residents received necessary care and services in accordance with professional standards and physician orders. Two residents with wounds did not receive all scheduled wound care treatments as ordered. Documentation showed that one resident missed wound care on multiple days due to being out of the facility or refusing treatment, with these instances recorded as refusals or absences on the Treatment Administration Record (TAR). However, there was no evidence that the physician was notified of the missed treatments, nor was there documentation that the residents were educated about the risks and benefits of missing wound care. Interviews with nursing staff and the Director of Nursing (DON) confirmed that education was not provided and that missed treatments were not consistently communicated to the physician or documented as required. Another resident receiving IV antibiotic therapy did not have daily assessments or vital signs documented, despite facility policy requiring daily monitoring for residents receiving skilled services. The resident's medical record showed vital signs were only taken on select days, and skilled charting was not completed daily during the course of antibiotic therapy. The DON confirmed that daily assessments and vital signs should have been documented for residents on IV antibiotics, but this was not done in this case. Facility policies reviewed by surveyors required that wound care be provided according to physician orders, that missed treatments be documented, and that residents be educated on the risks and benefits of refusing care. Policies also required daily vital signs and assessments for residents receiving skilled services. The survey found that these policies were not followed for the sampled residents, as evidenced by gaps in documentation, lack of physician notification, and absence of resident education regarding missed or refused treatments.