Failure to Obtain Physician Orders, Informed Consents, and Complete Wound Assessments for Debridement Procedures
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for one resident. Specifically, the facility did not obtain the required physician's orders and informed consents prior to performing bedside debridement procedures on the resident's scrotal and perineal/perianal wounds. Facility policy required a new and separate consent for each debridement session, and the procedure listed on the consent was to match the physician's order. However, review of the medical record showed that for two debridement procedures, there were no corresponding physician orders, and for one of the procedures, no informed consent was obtained or signed. Additionally, the consent obtained for one procedure did not match the procedure actually performed, as documented in the physician's operative report. Further, the facility failed to ensure that wound assessments were completed after the bedside debridement procedures. According to facility policy and staff interviews, wound assessments should be performed after each debridement, including documentation of wound measurements, drainage, and tissue type. Review of the resident's wound assessments revealed that after the debridement procedures, there was no documentation of wound measurements or assessments for the scrotal and perineal/perianal wounds. This lack of documentation occurred both immediately following the procedures and in subsequent weekly assessments. The resident involved had severely impaired cognitive skills for daily decision making and was admitted with significant wounds requiring ongoing care. Despite the complexity of the resident's condition and the need for careful monitoring, the facility did not follow its own policies regarding consent, physician orders, and wound assessment documentation. These failures were confirmed by interviews with the DON and LVN, who acknowledged that the required documentation and consents were missing from the medical record.