Failure to Administer Physician-Ordered Wound Care
Penalty
Summary
Staff failed to administer wound care treatment as ordered by the physician for a resident with multiple complex medical conditions, including morbid obesity, diabetes, congestive heart failure, and a deep tissue injury to the right lateral heel. The physician's order specified that the wound should be cleansed with normal saline, patted dry, treated with betadine, covered with an ABD pad, and wrapped with gauze daily and as needed during the night shift. Review of the Treatment Administration Record (TAR) showed documentation of the wound treatment being performed on one date, but observation revealed that the dressing had not been changed as required by the order. On observation, the dressing on the resident's right lateral heel was found to be dry and intact, with the date on the dressing indicating it had not been changed on the previous day as ordered. Certified Nursing Assistants present at the time confirmed that the wound treatment had not been performed according to the physician's instructions. This lapse in care was identified during a review of records, direct observation, and staff interviews, and was cited as a deficiency affecting one resident reviewed for wounds.