Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when a resident with pressure ulcers did not receive necessary wound care treatment and services as ordered by the physician on four specific dates. Documentation review revealed that there was no record of wound care being provided on those dates, and the assigned nurse did not document the care or any refusal by the resident. The resident's care plan included interventions for pressure ulcer prevention and treatment, and physician orders specified daily wound care regimens for multiple wound sites. Interviews with facility staff, including the ADON and DON, confirmed that it was the responsibility of the nursing staff to provide and document wound care according to physician orders. Both the ADON and DON were unaware that wound care had not been documented or potentially not provided on the identified dates. The ADON stated that she was not informed of any refusals by the resident, and the DON indicated that wound care might have been provided but not documented. The facility's wound care policy required documentation of wound care, including the date, initials of the person performing care, and any resident refusals or changes in condition. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and type 1 diabetes mellitus, and was assessed as having moderate cognitive impairment. The resident had an unstageable pressure injury, a surgical wound, and a skin tear upon admission. The lack of documentation and uncertainty about whether wound care was provided on the specified dates constituted a failure to ensure the resident received necessary treatment and services consistent with professional standards of practice.