Unauthorized Wound VAC Order Changes and Improper Implementation of Surgical Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to promote healing of a surgical wound for one resident with a deep incisional surgical site infection. The resident was admitted with hospital discharge orders directing that a wound VAC remain on the incision continuously for six days at 125 mmHg. The resident’s care plan identified a surgical wound and directed staff to provide wound care as ordered. However, when the orders were entered into the facility’s system, they were altered from the hospital discharge instructions. A subsequent physician order dated two days after admission directed staff to remove the wound VAC dressing and foam, cleanse and dry the wound, reattach the hose to the wound VAC, and initiate therapy at 125 mmHg continuous suction with wound care to be provided three times weekly. This order differed from the hospital’s directive to keep the wound VAC on continuously for six days. The Assistant DON independently changed the wound care orders without provider authorization, which was later confirmed by the DON. The facility’s Treatment Administration Record showed that the wound care order was carried out only once during the month, indicating that the prescribed wound VAC therapy was not implemented as intended. Nursing documentation noted that the wound VAC device was found set at 190 mmHg with no suction at the wound site and drainage observed under the dressing. During an interview, the DON stated she observed the same issues and that the resident’s wound had worsened, with the sutures dehiscing. The resident recognized that the wound did not look right and contacted her surgeon directly. The Nurse Practitioner reported she was not aware the wound had worsened and stated her expectation that hospital orders be entered as received unless a provider approved changes, confirming that the ADON should not have altered the wound VAC orders or settings without authorization.
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