Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards to promote healing and prevent infections. This deficiency was identified for a resident with a Stage 4 pressure ulcer on the left buttock and sacrum. The resident had a physician's order to cleanse the wound with Dakin's solution, but the wound care nurse used sodium chloride solution instead during a wound care observation. Although the wound care team recommended using normal saline instead of Dakin's solution, there was no documented evidence that this recommendation was implemented until several days later. The facility's policy required that recommendations made by wound care providers be reviewed and addressed by primary care providers within 48 hours. However, the physician's order for the resident's wound care was not updated to reflect the wound care team's recommendation to use normal saline. During a wound care observation, the wound care nurse realized the discrepancy and acknowledged that they should have checked the physician's orders before starting treatment and obtained a new order to use normal saline. Interviews with various staff members, including the wound care nurse, LPNs, and the wound care nurse practitioner, revealed a lack of communication and documentation regarding the change in wound care treatment. The wound care nurse practitioner had recommended discontinuing the use of Dakin's solution due to the absence of infection signs and the potential for skin damage with prolonged use. However, the recommendation was not communicated to the primary physician in a timely manner, resulting in a delay in updating the treatment orders.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #11’s physicians orders were reviewed by the medical provider on 2/18/25. The Medical provider agreed with the wound care provider’s recommendation to change the Dakin’s solution for cleaning the wound to normal saline. The physician’s order was reconciled and placed in the electronic medical record by the resident’s MD on 2/18/25. The Wound Care Nurse was provided with education regarding following physician orders, prior to start of a pressure injury treatment, that includes a physician’s orders administration competency. II. All residents with pressure injury have the potential to be affected by the same deficient practice. On this date, 3/10/25, there are a total number of 14 out of 223 residents who currently have pressure injury. All 14 residents’ wound care rounds recommendations by the Wound Care team were reviewed by the DNS and reconciled with the medical provider on 3/14/25. III. The Pressure Injury and Physician order [REDACTED]. The Wound Care Nurse Practitioner will be re-educated to provide all recommendations timely to the medical provider within 48 hours of consult by the Medical Director. A Wound Care Recommendation form was created by the DNS to facilitate communication between the wound care team and the MD. The DNS and/or designee will monitor pressure ulcer treatment recommendations to ensure all new recommendations have been addressed and reconciled with the attending physician. All licensed nursing staff will be re-educated by the Staff Educator regarding following physician orders [REDACTED]. All licensed nurses will complete a physician’s orders administration competency post education. All licensed nurses will receive education regarding the Wound Care Recommendation form by the Staff Educator. IV. The DNS and/or designee will conduct 5-10 treatment observations weekly for four weeks and then monthly for six months. The DNS and/or designee will review the Wound Care Recommendation form weekly for four weeks and then monthly for six months for compliance. Findings from both audits will be brought to QAPI monthly for review and discussion by the DNS and/or designee. V. The Director of Nursing will be responsible for compliance.