F0659

D

QMAs Performed and Documented Wound Care Outside Scope of Practice

Wabash, Indiana Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in which Qualified Medication Aides (QMAs) performed and/or documented wound treatments outside their legal scope of practice for a resident with a left great toe wound. Resident D had multiple diagnoses, including chronic systolic heart failure, chronic pain syndrome, venous thrombosis history, malnutrition, atherosclerosis of the lower extremities, and restless legs syndrome. A NP wound note from late December documented that an earlier toe wound had resolved but a new wound on the left great toe had developed, initially suspected as an arterial ulcer and later classified as trauma-related. The wound was described as full thickness loss, dry, without drainage, and measured 0.8 cm x 1.2 cm x 0.1 cm. The January MAR ordered cleansing of the left great toe with povidone iodine and leaving it open to air on the day shift, with monitoring for infection or worsening, and QMA 5 documented completion of this treatment on two dates.

In late January, nursing documentation indicated the resident’s left toe wound had reopened, was bleeding, and was wrapped with gauze, though the resident would not allow measurement. A February NP wound note recorded that the left great toe wound had reopened with partial thickness loss and measured 0.7 cm x 1.0 cm x 0.1 cm. The February MAR contained orders to cleanse the left great toe with povidone iodine and leave it open to air every day and evening shift, later specifying to cleanse and paint with povidone iodine and leave open to air, with monitoring for signs of infection or worsening. QMAs 5, 7, and 9 documented on multiple dates in February that they completed these wound treatments. A subsequent NP wound note in late February described the wound as stable, scabbed, with partial thickness loss and measuring 0.6 cm x 0.7 cm x 0.1 cm.

In March, the MAR continued the order to cleanse and paint the left great toe with povidone iodine and leave it open to air every day and evening shift, with monitoring instructions, and QMAs 5, 7, and 9 again documented completion of these treatments on multiple dates. During interviews, QMA 5 stated that QMAs were allowed to apply creams and powders but not to treat any stage 1 or higher wounds, and acknowledged it was possible she signed for Resident D’s wound treatments even though the wound had worsened and QMAs had stopped doing the treatment. QMA 9 stated QMAs could apply creams and powders but not treat stage 1 or open wounds, and reported that she watched a nurse complete Resident D’s wound treatment but signed it off in the MAR herself, believing she could apply povidone iodine to a wound. QMA 7 similarly indicated QMAs were not allowed to complete treatments above a stage 1 or on open wounds and said she had not completed the resident’s wound treatments because he had a “crater” on his toe. The DON, however, indicated QMAs could not complete wound treatments above stage 2, wounds with bandages, or invasive treatments, but believed QMAs could complete this resident’s wound treatment because the toe was left open to air. The state QMA scope of practice obtained from IDOH specified that QMAs may apply topical medications only to minor skin conditions, including stage one decubitus ulcers, and may not administer treatments involving advanced skin conditions such as stage II–IV decubitus ulcers, and also may only document medications they personally administered, not those given by another person or not administered at all.