Failure to Provide Surgical Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide surgical wound care according to physician orders for one resident with a surgical wound. The resident had an order for wound care to the right upper quadrant mid abdomen, which included cleansing, applying skin prep, antibacterial dressing, and foam, to be changed three times per week on specific days and as needed. Documentation in the Treatment Administration Record indicated that wound care was completed on a specific date, but both resident interview and direct observation revealed that the dressing had not been changed as ordered. The dressing was found to be dated several days prior, and the resident reported that the nurse did not return to complete the dressing change after being asked. Additionally, the resident stated that she had to request weekly for her PICC line dressing to be changed, or it would not have been done. Review of nurses' notes showed no documentation that the resident refused wound care during the relevant period. The Assistant Director of Nursing confirmed that the wound dressing had not been changed as documented. Facility policy required wound care to be provided per physician orders and for the date and time of care to be documented in the medical record, which was not followed in this instance.