Failure to Complete and Document Physician-Ordered Dressing Changes
Penalty
Summary
The facility failed to follow its own policies and procedures, implement care plans, and adhere to physician orders regarding dressing changes for four residents. Documentation review revealed that for each of these residents, there were multiple instances where nursing staff did not sign the Treatment Administration Record (TAR) to indicate that ordered dressing changes were completed. Interviews with facility staff, including the wound care nurse and the Director of Nursing, confirmed that if the TAR is not signed, it is assumed the treatment was not performed, and no alternative documentation was found to show the dressings were changed as ordered. The residents involved had complex medical histories, including diagnoses such as displaced femur fracture, diabetes mellitus, heart failure, end stage renal disease, chronic kidney disease, and wounds requiring specialized care. Physician orders for these residents specified detailed wound care regimens, including daily or scheduled dressing changes, wound assessments, and documentation requirements. Despite these orders, the TARs for each resident showed missing staff initials on multiple dates, and in some cases, there was no supporting documentation in progress notes to indicate the treatments were completed. Facility policies required consistent implementation of wound care protocols, including documentation of each dressing change and regular wound assessments. The failure to document or perform these dressing changes as ordered was acknowledged by both the wound care nurse and the Director of Nursing during interviews. The Infection Preventionist also emphasized the importance of timely dressing changes to prevent infection and further wound complications. The facility's own policies and residents' rights documents underscored the necessity of providing care as ordered and maintaining accurate records, which was not done in these cases.