Failure to Obtain and Administer Wound Treatments and Medications Upon Admission
Penalty
Summary
The facility failed to follow its policies and procedures to ensure that wound treatment orders were obtained and implemented upon a resident's admission, and failed to ensure that medications and wound treatments were administered as ordered. Upon admission, the resident had significant medical conditions including Type 2 Diabetes Mellitus with skin complications, Peripheral Vascular Disease, and a recent left foot amputation. The admission assessment documented multiple wounds, including a surgical wound on the left foot, a vascular wound on the left ankle, and a vascular wound on the left abdomen. However, wound treatment orders were not entered into the system until several days after admission, and there were gaps in the documentation of wound treatments and medication administration on the Treatment Administration Record (TAR) and Medication Administration Record (MAR). Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for entering and carrying out wound treatment orders. The admitting nurse did not complete a full body assessment or enter wound treatment orders, citing late admission and shift cut-off times. The nurse who completed the admission assessment entered medication orders but not wound treatment orders, and notified the DON and wound care nurse about the wounds. The wound care nurse was on vacation at the time, and the DON was not present in the facility, leaving floor nurses responsible for treatments. However, the night shift nurse did not perform wound treatments, believing they were not assigned, and the necessary orders were not in place for treatments to be carried out. Facility policies require that a full skin assessment and verification of treatment orders be completed upon admission, with prompt entry of orders and documentation of all treatments and medication administration. The failure to obtain and implement wound treatment orders and to document administration of medications and treatments resulted in missed care for the resident, as evidenced by unsigned entries on the TAR and MAR and staff statements confirming that if documentation is missing, the care was not provided.