F0684

D

Failure to Obtain Orders and Document Wound Care for Wrist and Elbow Dressings

Glendale, Arizona Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and document physician orders and corresponding wound documentation for dressings applied to a resident’s wrists and elbow. The resident was admitted with multiple complex medical conditions, including pleural effusion, acute respiratory failure with hypoxia, syncope and collapse, atherosclerotic heart disease, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, sick sinus syndrome, left bundle branch block, endocarditis, metabolic encephalopathy, acute embolism and thrombosis of the left peroneal vein, long-term anticoagulant use, and a cardiac pacemaker. The 5‑day MDS showed no BIMS score, but the admission assessment documented the resident as alert, cooperative, oriented, and with clear comprehension, and showed no evidence of wounds to the wrists or elbow. The admission care plan also contained no documentation of wounds or wound care to these areas.

During an observation, the resident was seen in a wheelchair with bandages on both wrists and the left elbow, none of which were dated or initialed. The resident’s daughter reported that the right wrist bandage was coming off, and nursing staff were notified. A review of the physician’s orders at that time revealed no wound care orders for either wrist or the left elbow, and there were no progress notes documenting wounds to these areas. Later that same day, an initial wound care order was entered only for the right wrist. On a subsequent observation, the right wrist dressing was dated and initialed, but the left wrist and left elbow dressings still lacked dates and staff initials. A follow‑up review of physician orders then showed wound care orders for the right wrist, left elbow, and left wrist, specifying cleansing with wound cleanser, patting dry, and applying a foam dressing twice daily as needed.

Interviews with nursing staff and leadership confirmed that facility expectations and policies required wound care orders for each wound, documentation of all wounds and treatments in the electronic health record, and that all dressings be dated and initialed by the nurse providing care. The RN who identified the loose bandage stated she had requested a wound care order for the right wrist and later noticed additional areas without knowing how long the dressings had been in place, and confirmed there were no orders for the left wrist or elbow at that time. The ADON verified that wounds present on admission should be identified in the admission assessment with corresponding orders, and that any bandaging must have matching orders and documentation. The wound care nurse stated she was not aware when the wrist and elbow injuries occurred and acknowledged that orders, wound documentation, and dated/initialed dressings were expected. Facility policies on wound documentation, standards of nursing practice, and charting requirements all required comprehensive assessment, daily monitoring, and treatment documentation, which were not followed for these wrist and elbow wounds.