Failure to Follow Wound Care and Laboratory Orders per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional standards, and facility policies for wound care and laboratory services. One resident with peripheral vascular disease and diabetes, who had all toes amputated on the left foot due to osteomyelitis, had no physician orders for left foot wound dressing changes from admission through early January. The resident reported always having to ask staff to change the dressing. An LPN confirmed there were no wound care orders and stated that dressing changes were done only when the resident requested them. The facility’s wound policy required obtaining treatment orders in the absence of existing orders and providing wound care per physician orders, but this was not followed for this resident’s post‑amputation foot wound. Another resident with cellulitis of the left lower limb and lymphedema had a physician order for left calf wound care specifying cleansing, application of methylene blue foam, abdominal pads, gauze wrap, and tape, to be changed three times weekly and PRN if saturated, soiled, or dislodged. Record review showed a scheduled dressing change was not documented as completed on a specific date, and no PRN dressing changes were documented over several days. On two separate observations, the resident was seen with an undated left leg dressing that was saturated with serous drainage and with the wrap falling off, requiring the resident to place absorbent materials (a bed pad, then a pillowcase) under the foot to contain the drainage. Interviews with nursing staff and a wound physician confirmed the expectation that dressings be changed as ordered and when wet or dislodged, which did not occur in this case. A third resident, cognitively intact with multiple comorbidities including renal failure, diabetes, and hyponatremia, had STAT orders for a UA with reflex to culture on two consecutive days, but the urine specimen was not obtained as ordered. The resident reported pain with urination and lower abdominal pain, stated they had not completed a urine test, and had not urinated on one of the observation days. An LPN acknowledged that urine had not been obtained and that the resident was not refusing. Subsequent orders for laboratory tests, including urine culture, were entered, and staff reported they were in the process of collecting labs and that normally a STAT UA should include straight catheterization if needed, which had not been done. Documentation later showed the UA was eventually completed days after the initial STAT orders, and interviews with nursing leadership indicated they were unaware of the missed and delayed UA and related hydration issues, despite facility policy requiring timely provision and follow‑up of ordered laboratory services. Overall, the facility did not follow its own Wound Treatment Management and Laboratory Services and Reporting policies, as residents did not receive wound care and laboratory testing in accordance with physician orders, professional standards, and stated expectations for timely treatment and documentation.
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