Failure to Complete and Document Ordered Wound Treatments
Penalty
Summary
The facility failed to implement ordered wound treatments for one resident who was admitted with diagnoses including diabetes, a pressure ulcer, and muscle weakness. The resident was assessed as cognitively intact, with a perfect score on the Brief Interview for Mental Status (BIMS). The resident reported that staff did not always complete her dressing changes as ordered. Review of the Treatment Administration Record (TAR) revealed multiple instances over several months where wound dressings for the resident's right lower anterior leg, right buttock, and left shin were not marked as completed by nursing staff. The Director of Nursing confirmed that there was no documentation indicating that the dressings were completed or refused on several specific dates. Additionally, refused dressing changes were not accompanied by corresponding progress notes explaining the circumstances, as required.