Missed and Falsely Documented Wound Care Treatments for Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care treatment according to physician orders, the resident’s comprehensive care plan, and professional standards of practice for one resident. The resident was an adult female with diagnoses including cerebral infarction, rash and nonspecific skin eruption, and MRSA infection. A quarterly MDS showed she was cognitively intact with a BIMS score of 15, used a wheelchair, was dependent for bed mobility and transfers, and was at risk for pressure ulcers but had no documented skin ulcers at that time. Her care plan included a focus on wound management with an intervention to provide wound care per treatment order. Physician orders and treatment records showed that the resident had an order to cleanse a right distal thigh wound related to lymphedema. An order for once-daily wound cleansing was active in January, and a new order for wound care at bedtime, and later twice daily due to drainage, was active from late January onward. On one January date, the Treatment Administration Record reflected that the wound care was not completed and an exception code of "Sleeping" was entered and signed by an LPN. There was no corresponding progress note documenting the missed treatment, any resident refusal, or other explanation on that date. During interview, the LPN later acknowledged she believed she might have missed one of the resident’s scheduled wound care treatments while assisting on the floor and being behind on medications, and she described the resident as not allowing wound care after a certain evening time. In early February, the Treatment Administration Record showed that another LPN documented completion of the resident’s bedtime wound care on two evening shifts. However, the wound care nurse reported that on the mornings following those shifts she observed the same bandage she had applied the prior day still in place, indicating the ordered evening wound care had not been performed despite being charted as completed. She stated she had noticed evening wound care being missed a few times and had not yet reported these findings. On observation, the resident’s wound was small and located on the right inner thigh, with the dressing dated the previous day. The resident reported that staff were performing wound care twice a day and denied any concerns or awareness of missed treatments. The wound care NP stated the wound was not progressing well and there was concern for possible infection, and she was not aware of missed treatments because the wound was always dressed when she assessed it. The DON and the administrator both stated that sleeping was not an acceptable reason to omit wound care without follow-up, and facility policies on wound care and charting required accurate documentation of treatments, refusals, and related resident information, which was not done in these instances.
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