Failure to Provide Wound Care as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with wounds received necessary treatment and services consistent with professional standards of practice. For one resident admitted with multiple wounds, including to the right ankle, buttock, thigh, and abdomen, there were several instances where wound care orders from the wound physician were not transcribed in a timely manner, resulting in incorrect or missed treatments. Specifically, wound treatments for the right buttock and abdomen were not updated according to new physician orders, leading to the resident receiving outdated treatments for several days. Additionally, documentation failed to show that certain wound treatments were completed as ordered on specific dates, and one wound treatment order for the right thigh was not transcribed or administered for 13 consecutive days. Another resident with a coccyx wound also experienced lapses in wound care management. The care plan required specific wound treatments and follow-up with the wound physician, but the treatment administration record did not show evidence that wound care was completed as ordered on multiple dates. When the wound physician updated the treatment order to a new regimen, the order was not transcribed until two days later, resulting in the resident receiving the incorrect treatment. There was also a missed wound treatment on the morning following the transcription of the new order. Interviews with the wound physician and the facility administrator confirmed that wound care orders were expected to be transcribed and treatments completed as ordered. However, the facility was unable to provide evidence that these processes were consistently followed, resulting in residents not receiving wound care in accordance with physician orders and professional standards of practice.