Failure to Follow Physician Orders for Post-Surgical Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide timely wound care to a resident with a left femur fracture surgically repaired prior to admission. The hospital discharge summary ordered Aquacel dressing to remain in place on the left surgical wound for seven days and then be replaced with new Aquacel. Upon admission, the Wound Nurse entered a physician’s order to cleanse the left lateral thigh wound with wound cleanser, apply a protective barrier to the peri-wound, and cover with a silicone foam with silver dressing every seven days and as needed. The resident’s care plan identified risk for complications from the left thigh surgical wound, with goals for healing without infection and interventions to observe for signs of infection, report abnormalities to the physician, and provide wound treatments as ordered. The MDS admission assessment documented that the resident had moderately impaired cognition, occasional rejection of care, and a surgical wound, but no wound care. From admission through mid-month, there was no documented evidence that wound care was provided to the resident’s left femur surgical wound. The TAR showed that on one date Nurse #6 coded wound care as not performed and directed to see progress notes, but the progress notes contained no explanation for the missed treatment and no documentation of any wound care from admission through that date. In interviews, Nurse #6 stated the resident refused wound care on that date and that she reported the refusal to the Wound Nurse, and also stated she never provided wound care to the resident at any time. The Wound Nurse confirmed that wound care had not been completed because of a reported refusal and that she did not document her own attempt when the resident refused on another day. A nurse aide reported that the resident sometimes refused care but would usually accept it with redirection or re-approach. When wound care was finally observed nearly two weeks after admission, the original hospital dressing dated several days before admission was still in place, and the Wound Nurse then removed it and applied a new silicone foam dressing. The DON and Medical Director both stated that wound care should have been provided according to the physician’s order and sooner than 13 days after admission.
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