Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for one resident, identified as Resident 19, by not following the physician's orders for wound treatment. Resident 19 had a Stage 4 pressure ulcer on the left heel and a non-stageable pressure ulcer at another site. The care plan indicated an actual skin breakdown on the resident's left great toe, requiring specific treatment as per physician's orders. These orders included cleansing the wound with Acetic Acid 0.25 percent, applying medical grade honey, and then applying Calcium Alginate before securing with gauze and paper tape. On December 16, 2024, during an observation of wound care, it was noted that the LPN did not apply the medical grade honey and Calcium Alginate as ordered. Instead, the LPN only cleansed the wound with Acetic Acid and applied a dressing soaked in the same solution, followed by a dry gauze and paper tape. This deviation from the prescribed treatment was confirmed through interviews with the LPN and the Assistant Director of Nursing/Infection Control Preventionist, indicating a failure to adhere to the physician's orders for wound care.
Plan Of Correction
1. Resident 19's treatment was properly completed per physician order. Licensed Practical Nurse was educated on following physician treatment orders. 2. Licensed Staff educated on following physician treatment orders. 3. Registered Nurse Assessment Coordinator or designee will audit three treatments weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.