Failure to Provide Prescribed Wound Care Due to Lack of Supplies
Penalty
Summary
The facility failed to provide the prescribed wound treatment for a resident with a stage 4 pressure ulcer. The resident had a physician's order for the wound to be packed with iodoform 5% gauze packing strips, but these supplies were not available for several days. The Director of Nursing (DON) was informed that the packing strips were running low and placed an order, but there was no inventory process in place to monitor supplies. The wound nurse did not contact the physician for new treatment orders when the prescribed supplies were unavailable, and the floor nurse substituted a different dressing (alginate 4x4) without a physician's order. Observations confirmed that the required gauze packing strips were not present on the treatment cart or in the supply room. The wound nurse acknowledged the lack of supplies and the absence of a process for reordering or notifying the physician for alternative orders. The resident's wound treatment was not performed as ordered, and documentation showed the facility's policy required evidence-based interventions and compliance with physician orders for pressure injury care.