Failure to Provide Consistent and Ordered Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, physician orders, and the resident’s preferences and goals. The resident, who had a complex medical history including diabetes, chronic kidney disease, and a diabetic foot ulcer, was simultaneously receiving wound care from both an outpatient wound clinic and the facility’s inhouse wound care team. Both providers issued different wound care orders, resulting in inconsistent and conflicting treatments, missed dressing changes, and inaccurate wound assessments. The resident reported that dressing changes were not performed daily as ordered, and sometimes were left for several days, leading to soiled and saturated dressings with visible drainage and active bleeding. Observations and interviews revealed that wound care was not consistently provided as ordered. For example, an LPN performed a dressing change using supplies and techniques not specified in the current orders, including the use of betadine, which was not ordered for the wound. The same soiled ace wrap and tape were reapplied after the dressing change. Documentation showed that wound care orders were frequently not followed, with missed treatments and conflicting orders being carried out on the same day. The facility did not consistently document wound assessments, failed to discontinue outdated orders, and did not ensure that only the most current orders were being followed. There was also a lack of communication and coordination between the inhouse and outpatient wound care providers, resulting in the resident arriving at outpatient appointments with incorrect dressings and supplies. Interviews with facility staff, including the DON, LPNs, RNs, and the inhouse wound nurse, indicated a lack of awareness regarding the resident’s dual wound care providers and the existence of conflicting orders. Staff did not consistently report or resolve order conflicts, and the DON had not audited treatment records to ensure compliance. The outpatient wound care provider and the resident both expressed concerns that the facility was not following the outpatient orders, and the resident’s wound ultimately deteriorated, requiring surgical intervention. Facility policy required regular skin assessments and adherence to wound care protocols, but these were not consistently implemented for this resident.