Failure to Provide Wound Care as Ordered and Inaccurate Documentation
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with multiple medical conditions, including a pressure ulcer on the coccyx. Physician orders specified daily cleansing of the coccyx wound with normal saline, application of collagen wound filler, and comfort foam, to be changed every day and as needed. However, during observation, the resident's wound dressing was found to be dated four days prior, shriveled, and appeared to have not been changed as required. The resident reported that the dressing was changed about once a week, and was observed scratching the wound, causing bleeding. Review of the Medication Administration Record/Treatment Administration Record showed that staff had initialed daily completion of wound care, including on days when the dressing had not been changed. Interviews with nursing staff and the Director of Nursing revealed that some nurses had documented completion of wound care without actually performing the dressing change. There was no documentation in the progress notes to indicate that the resident had refused care on the days in question. The facility's wound care policy was requested but not provided prior to the survey exit.