Failure to Provide Ordered Wound Vac Care and IV Site Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatment and adequate assessment for a resident with complex medical needs, including a wound vac and multiple IV lines. The resident was admitted with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, tracheostomy status, and depression, and had moderately impaired cognition and dependence on staff for toileting and bathing. From admission through discharge, there were no wound or skin assessments documented, despite the presence of an abdominal wound vac ordered at 100 mmHg suction with dressing changes scheduled for Monday, Wednesday, and Friday on dayshift. The record shows the wound vac was applied on one date, but there is no documentation of any subsequent wound vac dressing changes on the ordered days. The resident also had multiple peripheral IV lines, including sites in the left wrist, left shoulder, and right forearm. Progress notes describe IV pump alarms and attempts to use different peripheral lines, including removal of one access due to resident-reported pain and observed erythema beneath the transparent dressing, with notification of the NP and continuation of IV medications via another access. However, from admission through discharge, the progress notes and TAR contain no documentation of IV site care or monitoring of the access sites. In interviews, the DON confirmed that no skin or wound assessments were completed, no wound vac changes were performed after the initial application, and no IV site care was documented for this resident during the stay.
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