Failure to Perform and Accurately Document Ordered Wound Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered wound dressings were completed as prescribed for a hospice resident with multiple wounds. The resident was admitted with diagnoses including malignant neoplasm of the prostate, COPD, and a history of stroke, and had impaired skin integrity to the left great toe and left lower shin due to multiple falls. The care plan called for complete skin assessments per facility policy and completion of treatments as ordered. Physician orders directed that the left lower outer leg and left great toe wounds be cleansed with normal saline, dried, and treated with calcium alginate and non-bordered super absorbent dressings, secured and completed on the night shift. The Treatment Administration Record for November showed that these treatments were initialed as completed on three separate dates by nursing staff. However, during wound rounds on a later date, the wound nurse practitioner and wound nurse observed that the dressings on the resident’s left great toe and left outer lower leg had not been changed daily as ordered and were still dated several days earlier, confirming that the treatments had not actually been performed on the dates documented. The DON confirmed that an RN and an LPN had signed the TAR indicating the treatments were done when they had not been provided. Another LPN reported that when she went to perform the dressing change, she found the same dressing she had applied several days before still in place on both the leg and great toe. Personnel records documented disciplinary actions for the involved nurses related to signing off on treatments that were not completed and failure to meet reasonable performance standards.
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