Failure to Document and Obtain Orders for Resident Wound Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Parkinson's disease, dysphagia, and dementia was observed with an old bandage on their left forearm, dated several days prior, without any corresponding documentation or physician order. The resident was cognitively intact and able to communicate, but was unaware of the reason for the bandage. Multiple observations confirmed the bandage remained in place for several days, and there was no evidence in the medical record, Medication Administration Record, or Treatment Administration Record of any treatment orders or documentation regarding the bandage or a skin issue on the left forearm. Additionally, there were no progress notes or Incident and Accident forms explaining the presence of the bandage or any related skin condition. Interviews with nursing staff revealed a lack of awareness regarding the origin of the bandage and whether an order existed for its application or change. One LPN recalled changing the bandage but did not remember the underlying issue and assumed it had been reported. Both RNs and the Director of Nursing confirmed that any dressing should have an accompanying order and be documented, and that skin issues should be reported and tracked. The absence of documentation, orders, and reporting for the bandage and any associated skin issue constituted a failure to provide treatment and care in accordance with professional standards and regulatory requirements.