Failure to Provide Ordered Wound Care and Comprehensive Wound Assessment
Penalty
Summary
The facility failed to provide wound care as ordered for an arterial ulcer on a resident's right foot and did not complete a comprehensive wound assessment for a surgical wound on the same resident. Medical record review showed that the resident, who had diagnoses including COPD, diabetes mellitus, and peripheral vascular disease, was admitted with an arterial ulcer on the right foot second digit. Orders were in place for daily and as-needed application of barrier spray/wipes, but documentation on the Treatment Administration Record did not support that these treatments were completed as ordered. The wound physician's note and physician orders specified the required care, but the order was incorrectly entered into the electronic health record as 'as needed' only, rather than 'daily and as needed.' The resident later complained of the toe being dead, was hospitalized, and subsequently underwent amputation procedures. Further review of the medical record after the resident's return from the hospital revealed incomplete documentation regarding the surgical wound. Admission and weekly skin assessments noted the presence of amputated toes but did not include measurements or descriptions of the surgical site. Interviews with the Administrator and DON confirmed the lack of documentation for both the wound care provided and the assessment of the surgical wound, which was not in accordance with the facility's wound care policy that requires detailed recording of wound care and assessments.