Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
A deficiency occurred when wound treatments for a resident with multiple chronic wounds, including non-pressure ulcers on the right foot and calf, were not completed as ordered by the physician. The resident's medical record showed daily wound care orders, including cleansing with normal saline, application of calcium alginate with silver, and appropriate dressings. Documentation on the Treatment Administration Record (TAR) indicated that treatments were recorded as completed on consecutive days, but interviews and direct observation revealed that the treatments had not actually been performed. Specifically, the wound dressings had not been changed since two days prior, as evidenced by the date and staff initials on the gauze, and the resident reported not receiving wound care since the beginning of the week. Further investigation through staff interviews confirmed that one LPN documented completion of wound care before actually performing it, and another LPN admitted to not completing the treatment due to running out of time during the shift. There was no documentation in the resident's chart explaining the missed treatments, and the Director of Nursing confirmed that the wound care should have been completed as ordered. The deficiency was identified during a complaint survey and was substantiated by resident interview, staff interview, record review, and direct observation.