Inconsistent Wound Care Orders for Resident's Pressure Ulcer
Penalty
Summary
The facility failed to ensure that wound care practitioner recommendations were appropriately addressed for a resident with a sacral pressure ulcer. The resident, who was readmitted to the facility, had a wound consultant report indicating the presence of a sacral pressure ulcer. The consultant recommended specific treatments, including cleansing with 0.125% Dakin's solution, applying medical grade honey and calcium alginate, and covering with a bordered foam dressing. However, the facility had two active wound care orders for the resident's sacrum that specified different treatments, neither of which were consistent with the wound consultant's recommendations. An observation revealed that a licensed nurse performed wound care on the resident's sacrum, following one of the inconsistent orders. The Assistant Director of Nursing confirmed the discrepancy in the treatment orders and acknowledged that the facility typically follows the wound consultant's recommendations unless the attending physician specifies an alternative treatment. This inconsistency in following the recommended wound care protocol led to the deficiency noted in the report.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R271 wound treatment was corrected to the recommendations made by the wound consultant. The DON/designee audited the most recent wound report recommendations to ensure current recommendations are addressed and orders are in place and prior orders are discontinued. The DON/designee educated licensed staff on ensuring that the wound care practitioner recommendations are addressed and orders are in place and prior orders are discontinued. The DON/designee will audit the wound care practitioner recommendations to ensure recommendations are addressed and orders are in place as well as making sure prior orders are discontinued. Audits will be done weekly x 4 weeks and then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.