Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that staff met professional standards for a licensed nurse in following a physician's wound care order for a resident identified as CL1. The resident had an unstageable coccyx wound that required specific treatment as per a physician's order, which included cleansing with normal saline, applying Medihoney and Calcium Alginate, and covering with a dressing daily. However, the clinical records revealed that the wound was not treated on three specific days, and there was no documentation that the physician was notified of the missed treatments. Additionally, a new wound care order was issued, but the required Santyl medication was not delivered to the facility until four days later. During this period, the wound was treated with an alternative method not in accordance with the physician's order. The nurse responsible did not follow up with the pharmacy, inform the supervisor, or notify the physician about the unavailability of the medication and the deviation from the prescribed treatment. This failure to adhere to professional standards and facility policies was confirmed through staff interviews and a review of relevant records.
Plan Of Correction
Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Santyl was received January 27th and treatment applied appropriately on that date forward. Education and corrective action provided to team member involved January 27, 2025. Team member terminated 2/6/2025. Audits was done on past month of treatments to identify any trends and patterns. Completed February 6, 2025. Licensed staff educated on notification of physician's residents and resident representative if treatment is not available. Completed by February 8, 2025. Order set for wounds added to EMR, education provided to licensed team members on use of order set and documentation. Completed by February 8, 2025. Audits on wound order set began February 13, 2025 x 4 weeks.