Failure to Provide Scheduled Wound Care and Communicate Missed Treatments
Penalty
Summary
A resident with multiple diagnoses, including hypertension, dementia, and muscle weakness, was admitted with an open lesion on the right heel. The care plan specified that wound care was to be administered to the right heel on Monday, Wednesday, and Friday, as ordered by the physician. Documentation and observation revealed that wound care was not provided as scheduled on two occasions, with dressings on the heel dated several days prior to the surveyor's observation. The resident was noted to have severe cognitive impairment and required assistance with personal care. Interviews with nursing staff revealed that wound care was missed on the scheduled days because the responsible RNs were too busy and failed to complete the treatments. Both RNs admitted they did not inform the oncoming nurse or the DON about the missed wound care, as required by facility protocol. The DON confirmed she was not made aware of the missed treatments and stated that the expectation was for nurses to report and ensure completion of wound care if unable to perform it themselves. Facility policy required that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection, with nursing staff responsible for administering treatments as ordered. The failure to provide wound care as scheduled and to communicate missed treatments to supervisory staff constituted a lapse in following professional standards of practice and facility policy, resulting in a deficiency related to the prevention and treatment of pressure ulcers.