Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that two residents received wound care as ordered by their physicians, as evidenced by multiple missed or undocumented wound treatments. For the first resident, who was admitted with significant medical conditions including anoxic brain damage, severe contractures, impaired mobility, and incontinence, the care plan identified actual skin breakdown and multiple wounds, including pressure ulcers and arterial injuries. Review of the Treatment Administration Records (TARs) for September, October, and November revealed numerous blank entries where wound care orders were not documented as completed, including treatments for pressure ulcers, arterial ulcers, and skin tears, as well as required weekly skin assessments and offloading interventions. These omissions were confirmed through record review and interviews with the Director of Nursing (DON), who stated that facility nurses were responsible for implementing and documenting wound care orders received from an external wound care company. The second resident, admitted with diagnoses such as functional quadriplegia, dementia, and severe protein-calorie malnutrition, also had a care plan indicating actual skin breakdown, including multiple pressure ulcers and a trauma wound. Review of this resident's November TAR showed blank entries for several physician-ordered wound treatments, including the application of betadine, medihoney, and Triad Hydrophilic wound dressings to various wounds. These treatments were not documented as completed on the specified dates, and the DON confirmed that nursing staff were responsible for carrying out and documenting these orders. The facility's policy on documentation requires licensed staff and interdisciplinary team members to document all assessments, observations, and services provided in the resident's medical record. Despite this policy, the records for both residents showed repeated failures to document or complete ordered wound care treatments, as evidenced by the blank spaces in the TARs and confirmed by staff interviews.