LAKEWOOD, CO- VILLA MANOR CARE CENTER

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident received non-pressure-related wound treatment/care in accordance with physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Review of a care plan, date as revised 07/18/2022, revealed Resident #40 was readmitted for skilled, services following a hospitalization for osteonecrosis of the jaw. Interventions included to provide supportive care and assistance with mobility as needed, refer to physical and occupational therapy as ordered and as needed, and update the physician with changes in functional mobility. Further review of the care plan revealed Resident #40 was at risk for a break in skin integrity related to [CONDITION(S)] with impaired mobility; was usually continent of bowel and bladder; and was aware of toileting needs. Per the care plan, Resident #40 had ongoing issues with his/her jawbone, requiring multiple procedures, and frequently had incisions on his/her cheek. Interventions included to attend follow-up appointments for jaw treatments as ordered and follow up as needed by the wound team.

Review of the July 2022 Treatment Administration Record (TAR) revealed Resident #40 was to receive negative pressure wound therapy (wound vacuum). The order indicated the wound vacuum/dressing was to be checked for functioning with clamps open and dressing contracted every four hours. The TAR revealed no documentation this was completed as scheduled on 07/19/2022 at 12:00 AM, 4:00 AM, 12:00 PM, and 4:00 PM; on 07/26/2022 at 4:00 PM; and on 07/28/2022 at 8:00 AM, 12:00 PM, and 4:00 PM.

During an interview on 08/30/2022 at 3:43 PM, Resident #40 revealed the dressing was not changed timely, and the resident had to tell the nurses to do the treatments.

During an interview on 09/01/2022 at 4:51 PM, LPN #3 revealed she probably overlooked the treatment on the TAR for the wound treatments not documented as completed on 08/12/2022 and 08/13/2022 at 4:00 PM and failed to sign off that they were completed. The LPN stated she knew if it was not documented it was not  done. She revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

During an interview on 09/01/2022 at 5:18 PM, LPN #4 stated he was not sure why the treatments were not marked off as completed for the wound treatments due on 08/04/2022 at 8:00 AM, 12:00 PM, and 4:00 PM. He revealed he remembered checking on the wound vacuum that shift. He indicated that after administering medications or performing treatments, the residents’ MARs and/or TARs should be checked off as completed. He stated treatment orders should be followed and documented.

During an interview on 09/02/2022 at 9:14 AM, LPN #5 revealed she observed Resident #40’s wound vacuum but did not believe she even looked at or signed off the TARs for the wound care not documented as completed on 07/19/2022 at 12:00 PM and 4:00 PM. She stated she did not look at the order that indicated to check the wound vacuum every four hours. She indicated treatment orders should be followed and that treatments and/or medication administration should be documented.