Failure to Provide Daily Wound Care per Physician Order
Penalty
Summary
The facility failed to provide wound care treatment in accordance with physician orders and the resident's care plan for one resident. The resident, under 65 years old, had multiple diagnoses including vascular dementia, type 2 diabetes, diabetic neuropathy, atrial fibrillation, and hemiplegia following a stroke. The resident was cognitively intact and required substantial assistance with daily activities. According to the physician's order, the resident's venous wound on the left shin was to be cleaned and dressed daily during the day shift. However, during an interview and observation, it was found that the wound dressing had not been changed for three days, as evidenced by the date on the dressing and confirmed by staff during the dressing change. Staff interviews confirmed that the wound care order required daily dressing changes, and the wound care physician expected nursing staff to perform this task if the wound care nurse or physician was not present. The DON was unable to provide an explanation for why the dressing was not changed as scheduled. The failure to follow the physician's order for daily wound care resulted in the resident's dressing remaining unchanged for three days, contrary to professional standards of practice and the resident's comprehensive care plan.