Failure to Follow Hospital Discharge Wound Care Orders and Consult Physician
Penalty
Summary
A deficiency occurred when the facility failed to consult with a physician and follow hospital discharge instructions regarding wound care for a resident admitted after hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene. The resident, who had moderately impaired cognition, was discharged from the hospital with orders for a wound VAC (vacuum assisted closure) and vancomycin solution irrigation to be applied to a large right groin wound. Upon admission, these orders were not properly communicated or implemented by facility staff. Facility records and staff interviews revealed that the wound VAC and vancomycin solution were not available or administered as ordered. The admitting nurse, who was from an agency, did not ensure the wound care orders were entered or followed. Other nursing staff were unaware of the specific wound care requirements until several days after admission, and the vancomycin solution was never ordered. The wound VAC was not ordered until staff discovered documentation in the resident's room, and it was delivered two days after admission. During this period, the resident did not receive the prescribed wound care, and documentation of wound care was missing for several shifts. When the wound VAC was finally to be applied, staff discovered the resident's wound was contaminated with stool, and the resident was experiencing significant pain. The physician determined that the wound VAC had not been applied as intended and that the wound was at risk due to contamination. The resident was subsequently sent to the emergency room for wound care. Interviews with staff and review of records confirmed that the facility did not consult with a physician when unable to obtain the necessary wound care supplies and did not follow the hospital's discharge instructions for wound management.