Failure to Provide Physician-Ordered Wound Care and Accurate Documentation
Penalty
Summary
The facility failed to provide wound care as ordered by the physician for one resident with a history of atrial fibrillation, type II diabetes, chronic venous hypertension with ulcer and inflammation of the left lower extremity, and pulmonary hypertension. Physician orders specified daily wound care to the resident's left lower extremity, including cleansing, application of a silver collagen sheet, hydrogel dressing, and securing with kerlix and tape, with documentation required on the Treatment Administration Record (TAR). However, review of the TAR and direct observation revealed that wound care was not performed or documented on several days as required. The wound dressing was observed to be dated several days prior, and the resident reported that her dressing had not been changed recently, despite believing daily care was required. Interviews with the DON, LPN, and wound care nurse confirmed inconsistencies between the documented wound care and actual care provided. The DON acknowledged that the TAR indicated wound care was completed on certain days when it was not, and the wound care nurse stated he was unaware of any issues with wound care completion, as no staff had requested assistance. The LPN could not explain discrepancies between her initials on the TAR and the actual dates wound care was performed. Record review and staff interviews confirmed that the physician's order for daily wound care was not followed, and documentation was inaccurate.