Missed Wound Care Treatments Due to Documentation and Order Entry Errors
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including diabetes, dementia, heart failure, and a history of skin ulcers, did not receive prescribed wound care for a skin tear on the right shin over a period of several days. The resident was dependent on staff for several activities of daily living and was identified as being at risk for pressure ulcers and skin injuries. Physician orders specified that the skin tear should be cleansed and dressed on a set schedule, but these treatments were not administered as ordered between 10/03/2025 and 10/09/2025. The failure to provide wound care was due to a combination of documentation errors and incorrect order entry in the electronic medical record. The treatment nurse entered the order with the wrong timing, specifying treatments at night rather than once daily, which led to missed treatments. Additionally, another nurse mistakenly documented that treatments had been completed on certain dates when they had not been performed. These errors were discovered after the resident's family noticed an outdated bandage and contacted the facility, prompting a review of the medical record and identification of the missed treatments. Interviews with nursing staff and facility leadership confirmed that the resident did not receive the required wound care during the specified period. The treatment nurse acknowledged responsibility for entering the incorrect order and failing to ensure treatments were completed, while the ADON and DON were identified as responsible for monitoring treatments. The facility's policy required prompt treatment of skin concerns, but this was not followed in this instance, resulting in a lapse in care for the resident.