Delay in Wound Vac Supplies Resulting in Missed Ordered Treatment
Penalty
Summary
A resident with diagnoses including orthopedic aftercare, acquired absence of the left great toe, and type 2 diabetes was not provided wound vac supplies in a timely manner, resulting in a failure to implement ordered wound care according to professional standards and the resident’s care plan. On 6/5/25, a progress note documented that the resident had returned from a wound clinic appointment with instructions to order a wound vac, send it with the resident to the next appointment, and consider hyperbaric oxygen therapy. The note indicated that the DON and ADON were aware of these requests and orders. On 6/13/25, another progress note documented that the resident returned from an appointment with instructions that the wound vac was to be used on Monday, Wednesday, and Friday, with dressing changes every two days. The physician’s note/orders at that time stated to start the wound vac as soon as possible to the left foot, but also documented that they were unable to place the wound vac due to lack of supplies. On 6/16/25, a formal order was documented for a wound vac to the left foot, specifying that the wound vac should be in place and functioning, with changes on Monday, Wednesday, Friday, and as needed for wound healing. Despite these orders and the facility’s established process for obtaining wound vacs and supplies, the resident did not receive the necessary supplies in a timely manner. During interviews, an LPN stated that wound vacs were supplied by a contracted company and were brought the same day they were ordered, with all needed supplies. The DON stated that wound vacs arrived within two hours on the day they were ordered and that it would not take more than a week for a wound vac and supplies to be delivered, but she was unsure why it took so long for this resident to receive wound vac supplies. This discrepancy between the facility’s stated process and the actual delay in obtaining supplies led to the resident not receiving ordered wound vac treatment as prescribed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.