Failure to Provide and Document Ordered Wound and Dermatologic Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, consistent, and properly documented dermatologic and wound treatments as ordered and care planned for two residents. For one resident admitted for nerve pain, the care plan identified a pressure ulcer on the buttocks and risk for skin impairment, with interventions including weekly skin checks, measurements of the wound, nutritional support, preventive skin treatments, and prompt incontinence care. Physician orders directed cleansing of bilateral lower legs with normal saline, patting dry, and wrapping with a dry dressing every evening shift, as well as cleansing an area between the buttocks with 1/4 Dakins and applying zinc oxide every shift. Review of the Treatment Administration Record (TAR) showed missing treatments for the lower leg wound care order on multiple dates and missing treatments for the buttocks wound care order on several shifts. Further review showed an additional physician order for wound care to bilateral lower legs every dayshift, also with missed treatments documented on the TAR. The wound care nurse stated her responsibilities were limited to residents with stage three or greater pressure wounds, while "cart nurses" were responsible for less severe wounds and weekly wound assessments. An LPN identified as a cart nurse reported that she completed wound assessments weekly and provided wound treatments when ordered, and that she always completed treatments by the end of her shift or notified the next shift or manager if unable to do so. Despite these statements, the TAR documentation reflected that ordered treatments for this resident’s wounds were not consistently completed as prescribed. For another resident admitted with a several-week history of a rash on both feet, a dermatology consultation diagnosed tinea pedis and prescribed 2% Ketoconazole cream to be applied daily to both feet until resolved. On interview, the dermatologist confirmed the daily application order and stated that failure to apply the cream as ordered could result in worsening fungal infection and secondary complications. Multiple LPNs gave conflicting information regarding the use and availability of the Ketoconazole cream: one LPN initially stated she applied the cream to the resident’s belly button, then corrected herself to say it was for the feet, and presented an unopened tube dated with the resident’s name, explaining that a previous tube had been thrown away that morning. Other LPNs stated that only one tube had been obtained from the pharmacy, that it had not been refilled, and that the tube should last approximately two and a half to three weeks if used as ordered. Family members reported the resident had not received the prescribed cream for several days after admission and expressed concern that the ordered daily treatment had been missed.
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