Failure to Provide and Document Ordered Wound and PICC Line Care
Penalty
Summary
Surveyors identified deficiencies in the facility's provision of treatment and care according to physician orders and professional standards for two residents. For one resident with a history of stroke, congestive heart failure, and diabetes, there was a lack of ongoing skin assessments and incomplete documentation and administration of ordered wound care. The resident was admitted with three stage 2 pressure ulcers, and although an initial treatment order was in place, weekly skin assessments were not consistently performed or documented between late November and mid-December. The Treatment Administration Record showed that wound care was only documented as completed on six out of twenty-two days, and there was minimal progress note documentation regarding the resident's wounds during this period. Interviews with nursing staff revealed uncertainty about wound care responsibilities and processes, and the wound care provider was not involved as expected. For another resident with macular degeneration, congestive heart failure, and diabetes, there was a delay in obtaining orders for PICC line dressing changes and incomplete documentation of required PICC line flushes. Upon admission, the resident had a double lumen PICC line, but no orders for dressing changes or monitoring were obtained until several days later. The Treatment Administration Record indicated that PICC line flushes were only documented as completed three out of eleven scheduled times over a four-day period. There was also no evidence that the PICC line dressing was changed or that required measurements and assessments were performed as ordered. Nursing staff interviews confirmed that initial assessments and ongoing care for the PICC line were not consistently performed or documented. The facility's policies required thorough documentation and adherence to physician orders for wound and PICC line care, including regular assessments, dressing changes, and completion of treatments as ordered. However, the survey found gaps in both the performance and documentation of these essential care activities. Staff interviews highlighted a lack of clarity regarding responsibilities and processes for wound and PICC line care, contributing to the deficiencies observed during the survey.