Failure to Complete and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to complete a physician-ordered wound treatment for one resident with chronic ulcers and a history of a right femur fracture. The resident's care plan required wound dressing changes to both knees twice daily, as ordered by the physician. On the day of the survey, the resident reported that the dressing changes had not been completed as scheduled, and the dressings present were dated from the previous day. Observation confirmed that both knee dressings were overly saturated with serosanguinous drainage, which had soaked through to the pillowcases and towels placed under the knees, as well as onto the bed. The resident stated that this was a common occurrence and that the dressing changes were not consistently performed twice daily as ordered. Record review showed that the Treatment Administration Record was signed off as if the wound dressing change had been completed that morning, despite the treatment not having been performed at that time. The physician's order specified the application of Gentamicin Sulfate Cream to the left knee twice daily at specific times. Nursing staff confirmed that the dressings were overdue and that the documentation did not accurately reflect the care provided. The facility's policy required prompt documentation of treatments after administration to validate that residents receive care as ordered, which was not followed in this instance.