Failure to Provide Wound Care per Physician Orders and Professional Standards
Penalty
Summary
The facility failed to provide wound care to a resident in accordance with physician orders and professional standards of practice. The resident, an elderly male with multiple diagnoses including vascular dementia, peripheral vascular disease, and a history of severe lower extremity wounds, was admitted with specific wound care instructions from the hospital and subsequent orders from the wound care nurse practitioner (NP). These orders included cleaning and dressing the wounds at specified intervals (ranging from every 72 hours, three times a week, to daily, depending on the dressing type and wound status) and performing dressing changes as needed (PRN) when dressings became soiled. Documentation and interviews revealed that wound care was missed on several ordered dates, and PRN dressing changes were not performed or documented when dressings were visibly soiled with drainage or blood, as evidenced by photographs and staff observations. Multiple staff interviews confirmed that the resident's dressings were observed to be soiled on several occasions, with visible blood or drainage on the outer bandages. Despite this, there was no documentation of PRN dressing changes on the treatment administration records (TAR) or in progress notes. Staff, including LVNs, RNs, and CNAs, reported seeing soiled dressings and, in some cases, notifying the nurse responsible, but the dressings were not always changed as required by the physician's orders. The wound care NP and other nursing staff clarified that the frequency of dressing changes should have matched the wound care orders, and that soiled dressings should have been changed promptly to prevent complications. However, inconsistencies in order entry, communication, and follow-through led to lapses in care. Further review of facility processes revealed that wound care orders were sometimes entered incorrectly or not updated to reflect the most current recommendations from the wound care NP. There was confusion among staff regarding the correct frequency for dressing changes, particularly when orders changed from one type of dressing to another (e.g., from xeroform to calcium alginate). The facility lacked a policy to ensure that physician orders were consistently reviewed and updated in the electronic health record, contributing to the failure to provide wound care as ordered. Interviews with administrative staff confirmed that there was no formal policy on following or updating physician orders, and that responsibility for reviewing and reconciling orders was not clearly defined or consistently executed.