Failure to Administer Ordered Wound Care and Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure treatments and medications were administered as ordered for two residents. For one resident with diabetes, hypertension, peripheral vascular disease, and multiple chronic wounds, the care plan called for wound treatments per physician orders and weekly skin assessments. A physician order directed daily and PRN cleansing of the left heel with wound cleanser, application of Aquacel AG, and coverage with foam dressing. The treatment administration record (TAR) showed that on multiple days the wound treatment was not completed because the resident was at dialysis, and there was no documentation that these missed treatments were completed on another shift. Progress notes from the same period contained no documentation regarding the wound treatment, and a wound care company later noted a dressing dated several days earlier on the left heel. Further observations showed that when the LPN removed the left heel dressing, the wound measured approximately 3.0 by 5.0 cm with a red and yellow base, and the LPN reported finding the dressing unchanged at times, despite orders for daily treatment. The TAR continued to show additional missed treatments on days the resident was at dialysis, again without documentation that the treatments were completed later. An MRI subsequently confirmed osteomyelitis of the left heel, and the resident was sent to the emergency room based on those results. The DON, physician/Medical Director, and Administrator each stated they expected staff to complete dressing changes and orders as written, and the DON reported she was unaware that treatments were not being completed as ordered. For a second resident with diagnoses including hypertension, anxiety, and depression, a physician order required levothyroxine 175 mcg to be administered every morning at 6:00 A.M. The medication administration record (MAR) for the month showed numerous days when the levothyroxine was not administered. Progress notes documented that the levothyroxine was not given on at least two specific dates and that the physician and family were aware, but there was no further documentation addressing the other missed doses. An LPN working night shift acknowledged awareness that the levothyroxine was not available and could not explain why, stating that medications are usually ordered by the day-shift CMT and assuming the medication was on order. The DON stated she expected staff to notify her when medications could not be obtained and to notify the family and physician each time a medication was missed, and the physician/Medical Director stated she expected to be notified when an ordered medication was not received.
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