Failure to Provide Ordered Wound Care and Timely Wound VAC Application
Penalty
Summary
A resident was admitted to the facility following hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene of the right groin, with a significant wound requiring specialized care. Upon admission, the resident had physician orders for wound care, including the use of a wound VAC and vancomycin solution irrigation, as well as a Foley catheter to maintain cleanliness. However, the facility failed to implement a baseline care plan addressing the resident's wounds, and the wound care orders were not accurately or promptly entered into the treatment administration record (TAR). The only wound care documented was a single wet-to-dry dressing change, and there was no evidence that the vancomycin solution was ordered or administered as prescribed. The facility did not ensure the timely provision of a wound VAC, which was specifically ordered to prevent contamination of the wound with stool due to its location and severity. The wound VAC was not ordered until several days after admission, and it did not arrive until the morning the resident was sent back to the hospital. During this period, the resident's wound was left exposed and ultimately became contaminated with stool, as documented by both a physician assistant and a physician who assessed the resident. The lack of appropriate wound care and delay in obtaining the wound VAC resulted in the resident experiencing significant pain and required transfer back to the hospital for further treatment. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's wound care needs and orders. The admitting nurse was from an agency and could not be interviewed, while other nursing staff were unaware of the specific wound care orders until documentation was found in the resident's room. The facility's documentation and assessment of the wound were also inaccurate, misclassifying the wound type and failing to measure it upon admission. No additional evidence was provided to support that the resident received the ordered care during the period in question.