Failure to Follow Physician Orders and Document Wound Care
Penalty
Summary
The facility failed to assess and follow physician treatment orders for non-pressure wound care for two residents. For one resident with peripheral vascular disease, traumatic compartment syndrome, diabetes, and atrial fibrillation, there was a lack of documentation regarding wound measurements or assessments for vascular wounds on both heels. The treatment administration record showed missed or undocumented wound care on scheduled days, and there was no evidence that the provider was notified when the resident refused wound care. Additionally, a vascular surgery clinic note indicated that the resident had not received proper wound care at the facility, and the family expressed distress over the lack of care during a medical appointment. For another resident with moderate cognitive impairment, esophageal obstruction, dysphagia, heart failure, and chronic kidney disease, the care plan required regular skin evaluations and specific wound care for a skin tear on the left calf. The treatment administration record revealed missed documentation of scheduled wound care, and during an observation, the dressing applied was not consistent with the physician's order. Staff interviews confirmed that the correct dressing was not used and that wound care was not always performed as ordered. Facility policy required verification of physician orders, adherence to care plans, and notification of supervisors if wound care was refused. However, staff interviews and record reviews demonstrated that these procedures were not consistently followed, resulting in missed or improper wound care and lack of appropriate documentation and communication regarding resident refusals and wound status.