Failure to Provide Physician-Ordered Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when a resident with a Stage III pressure ulcer on the left sacrum did not receive the physician-ordered wound care following a surgical excisional debridement. The wound physician had ordered discontinuation of skin prep and initiation of leptospermum honey and a gauze island with border to be applied once daily and as needed. However, during wound care, a registered nurse cleansed the area and applied skin prep, contrary to the new orders. The nurse was unaware of the updated treatment plan at the time of care. The director of nursing confirmed that the new order had not been processed and the required leptospermum honey was not available at the facility, resulting in the resident not receiving the prescribed treatment. The facility's policy required wound treatments to be provided according to physician orders, including the specified cleansing method, dressing type, and frequency, but this was not followed in this instance.