Failure to Provide Physician-Ordered Wound Care for Multiple Residents
Penalty
Summary
The facility failed to implement physician-ordered daily wound care treatments for five residents who were at risk for or had existing wounds and pressure injuries. On two specific dates, the Treatment Administration Record (TAR) showed that required wound care was not provided as scheduled for these residents. The affected individuals had complex medical histories, including quadriplegia, colostomy, contractures, dementia, and existing pressure injuries, and were dependent on staff for most activities of daily living. Physician orders included specific wound care regimens such as cleansing with normal saline, application of Santyl collagenase ointment, use of barrier creams, and monitoring of low air loss mattresses, all of which were not carried out on the identified dates. 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 complete or document the required care on another. The Registered Nurse Supervisor, who was present during one of the shifts, acknowledged that no alternative licensed nurse was assigned to complete the treatments, nor was there any communication regarding the missed care. The Director of Nursing confirmed that despite being aware of the staffing gap, she was unable to ensure all necessary treatments were provided, resulting in multiple residents missing their prescribed wound care. Facility policy required that medications and treatments be administered only upon written physician orders, and that wound treatments be managed according to clinical protocols. The failure to follow these orders and protocols led to a lack of daily wound care for residents with significant risk factors for skin breakdown and delayed healing. There was no documentation of treatments being completed, refused, or held, and no evidence that missed treatments were reported to the physician or other responsible parties.