Failure to Implement and Document Wound Care Orders Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that residents received wound care treatment and services in accordance with professional standards of practice and their comprehensive care plans. For two residents with surgical wounds, the facility did not implement wound care orders as prescribed by the Wound Care Nurse Practitioner (NP). In one case, a male resident with a recent right below-the-knee amputation and multiple comorbidities, including diabetes and peripheral vascular disease, did not have wound care orders implemented or documented as required. Despite having clear orders to cleanse the wound, apply xeroform, and cover with a dry dressing, there was no evidence in the Treatment Administration Record (TAR) that wound care was performed throughout the month. The Director of Nursing (DON) was unable to explain the lack of documentation or implementation and acknowledged the importance of following wound care orders. The resident was later hospitalized for a non-healing, infected surgical wound, and required further surgical intervention. A second resident, a female with a history of lower leg fracture, congestive heart failure, and diabetes, also did not receive timely implementation of wound care orders. The Wound Care NP had provided specific instructions for wound care, including the use of wound cleanser, xeroform, medical honey, and calcium alginate, but these were not transcribed or carried out as ordered. The DON reported not being able to access the wound care provider's progress notes for a period, which contributed to the delay in implementing the orders. The Wound Care NP was not aware that her orders had not been followed until much later and stated that failure to implement the prescribed wound care could have led to wound deterioration. Interviews with staff revealed a lack of awareness and inconsistent understanding of the wound care orders, with one LVN stating that only bandaging was performed, contrary to the NP's orders. The facility's own wound care policy required documentation of wound care, including the date, initials of the person performing care, and any changes in the resident's condition, but this was not followed. The surveyor identified these failures as resulting in actual harm and Immediate Jeopardy, as residents with surgical wounds did not have their treatments performed as ordered, leading to wound infection and deterioration.