Failure to Provide Wound Care as Ordered and Inadequate Monitoring
Penalty
Summary
The facility failed to provide necessary wound care services to a resident with a full thickness skin tear on the right lower leg. The physician's order specified the application of Steri-Strips every shift for 21 days, monitoring for infection or drainage, and specific actions if drainage or infection was noted. Medical record review showed that the treatment administration record was marked as completed, but interviews with nursing staff revealed inconsistencies in the actual care provided. Staff reported using a foam dressing instead of Steri-Strips and did not consistently open the dressing to assess the wound, relying instead on monitoring for pain and discharge around the dressing. The treatment nurse admitted to cleansing the wound without a physician's order and acknowledged that the wound care orders were incomplete and should have been clarified. Documentation in the resident's progress notes indicated the presence of a full thickness skin tear with visible adipose tissue and serosanguinous drainage, and later development of cellulitis requiring antibiotic therapy. The care plan included providing treatment as ordered, but staff interviews and record reviews indicated that the wound was not always treated according to the physician's instructions, and wound monitoring and documentation were not accurately performed. These actions and inactions led to a failure in providing the necessary wound care services as ordered.