Missed Physician-Ordered Wound Care for Resident with Chronic Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, total dependence for activities of daily living, incontinence, and multiple chronic wounds did not receive physician-ordered wound care on a specified date. The resident, who had a history of Alzheimer's disease, malnutrition, abnormal posture, muscle wasting, and was at high risk for pressure ulcers, had orders for daily wound cleansing and dressing changes for multiple wounds on both feet. Documentation and direct observation confirmed that no wound care was provided on the missed date, and the dressings remained unchanged from the previous day. During an interview and observation the following day, the LVN responsible for the resident's care admitted to not performing the wound care, citing a busy shift and failing to communicate the missed treatment to the oncoming shift. The resident was found with saturated, foul-smelling dressings, particularly on the right foot, which was also edematous. The LVN acknowledged awareness of the daily wound care orders and expressed regret for not completing the treatment as required. The DON confirmed that weekend wound care was the responsibility of the assigned nurses and was unaware that the treatment had been missed until after the fact. The wound care physician stated that the wounds were chronic with a poor prognosis, but emphasized the importance of daily dressing changes to prevent odor and further deterioration. Facility policy required wound treatments to be provided as ordered and documented accordingly, which did not occur in this instance.