Failure to Follow Physician Orders for Wound Care Treatment
Penalty
Summary
Staff failed to follow physician orders for wound care treatment for a resident with a left below-the-knee amputation surgical site. The resident had intact cognition and required specific wound care interventions as documented in the care plan and treatment administration record, including the use of Vashe Wound Cleanser and Vashe-moistened gauze as part of the dressing change protocol. During an observed dressing change, a registered nurse cleansed the wound with normal saline and applied Xeroform instead of the ordered Vashe treatment. The resident reported that Vashe had not been used for the past three days and that Xeroform was used instead. The nurse explained that the process for changing a treatment order involved documenting the resident's refusal of Vashe and notifying the provider to request a new order for Xeroform, with documentation required in the nursing progress notes. However, the director of nursing confirmed that Vashe was unavailable prior to the dressing change and emphasized the expectation that staff follow physician orders and notify the physician if a treatment is refused. Facility policy requires that active orders be followed as written and that any changes be properly documented and communicated.