Failure to Provide Ordered Wound Care and Offloading Interventions
Penalty
Summary
The facility failed to provide wound care and offloading as ordered for two residents reviewed for skin integrity. For one resident who was admitted after a left total hip replacement, the hospital discharge summary included an order for Aquacel dressing to be changed every 5-7 days or as needed. However, this order was not transcribed into the facility's physician orders, and instead, a daily cleansing and dry dressing order was implemented. Multiple nurses observed the Aquacel dressing in place but did not clarify the discrepancy between the observed dressing and the written orders. Documentation in the Treatment Administration Record (TAR) and nursing notes reflected confusion and lack of action to clarify or implement the correct wound care protocol. The Aquacel dressing was not changed within the specified timeframe, and the correct order was only identified after review by the Wound Treatment Nurse several days later. Another resident with a left neck/shoulder contracture and a history of rheumatoid arthritis, diabetes, and cellulitis had a physician order to offload the contracture and keep the neck fold clean and dry every 8 hours. Observations and interviews revealed that the offloading and moisture-wicking interventions were not consistently implemented as ordered. Nursing staff failed to ensure that offloading devices or moisture-wicking fabric were in place, and documentation in the TAR showed missed treatments. Nurses interviewed could not recall if the interventions were performed and acknowledged missing the order. Both deficiencies were confirmed through record review, staff interviews, and direct observation. The failures included not following hospital discharge orders for wound care and not implementing or documenting offloading and moisture management for a contracture as ordered. These lapses were not questioned or clarified by nursing staff, leading to a lack of appropriate treatment and care as specified in the residents' care plans and physician orders.