Failure to Provide Physician-Ordered Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and treatment for a wound for one resident. According to the facility's policy, wound care must be performed with a physician's order, and all dressing changes must be documented with the date, time, staff involved, and type of dressing used. However, review of the clinical record for a resident admitted with diagnoses including high blood pressure, diabetes, and anxiety revealed no physician order for wound care from 9/26/25 to 10/6/25. During observation, the resident was found with an undated dressing on the left forearm, which the resident reported had not been changed since it was applied two days prior. Staff interviews confirmed the presence of the undated dressing and the absence of a physician order for wound care. The Nursing Home Administrator acknowledged that the facility did not provide appropriate care and treatment for the resident's wound.