Failure to Provide Physician-Ordered Wound Care and Treatment
Penalty
Summary
The facility failed to implement physician-ordered daily wound treatments for five residents on two separate days. These residents had significant medical needs, including quadriplegia, colostomy status, open wounds, dementia, contractures, hemiplegia, hemiparesis, and severe cognitive impairment. Physician orders for wound care, skin management, and monitoring of specialized equipment such as low air loss mattresses and casts were not carried out as scheduled. Documentation confirmed that the required treatments were not provided, and there was no record of treatments being completed, refused, or held. Interviews with facility staff revealed that the treatment nurse, who was responsible for administering these treatments, was absent on one of the days and did not report missed treatments on another. The Registered Nurse Supervisor, who was aware of the absence of a treatment nurse, did not reassign the responsibility to another licensed nurse or ensure that the treatments were completed. The Director of Nursing acknowledged that she attempted to provide treatments herself but was unable to complete all required treatments for residents with extensive or complex wound care needs. Facility policy required that medications and treatments be administered only upon written physician orders and that licensed nurses demonstrate competency in providing care as identified in resident assessments and care plans. The failure to follow these orders and policies resulted in residents not receiving necessary wound care and monitoring as prescribed by their physicians.