Failure to Communicate Wound Care Recommendations and Monitor Wound Progress
Penalty
Summary
Nursing staff failed to ensure that care and services provided to residents with wounds met professional standards of quality. For two of three sampled residents who received wound care services, the facility did not notify the attending physician of recommendations made by wound care clinicians, nor did they adequately monitor and assess the residents' wounds to determine if the areas were improving or deteriorating. Facility policy required that all recommendations from consulting providers, such as wound clinics, be reviewed with the attending physician for approval or denial, and that the effectiveness of interventions be monitored through ongoing assessment and documentation in the medical record. One resident with a history of schizophrenia, bipolar disorder, diabetes with neuropathy, and a non-healing left hip surgical wound that developed into a Stage IV pressure injury, was seen monthly at an outpatient wound clinic. The clinic provided specific treatment recommendations, including wound care orders and interventions for pressure injury management. However, there was no documentation that these recommendations were reviewed with or brought to the attention of the attending physician, nor was there evidence that physician orders were obtained for new treatments. Additionally, nursing staff failed to document measurements or monitor the progress of the resident's wounds in weekly skin assessments, nurse progress notes, or treatment administration records, despite facility policy and staff statements that such monitoring was required. Another resident admitted with dementia, repeated falls, and depression, had bilateral unstageable pressure injuries to the heels. The in-house wound care specialist recommended an air mattress for pressure redistribution, but there was no documentation that this recommendation was communicated to the attending physician, and the resident did not have an air mattress in place. Furthermore, after initial assessment and staging of the heel wounds, subsequent weekly skin assessments and nursing documentation failed to record observations, measurements, or monitoring of the wounds' progress. Interviews with facility staff confirmed that recommendations from wound care providers should be reviewed with the attending physician and that weekly wound measurements were expected but not completed.