Failure to Timely Implement Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure ulcers for a resident with a gluteal cleft pressure injury. The resident, who had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, muscle weakness, and a nontraumatic intracerebral hemorrhage, was under the care of a wound nurse practitioner (NP) who recommended a specific wound care regimen. The NP's recommendations, which included cleaning the wound with cleanser, applying honey and a dry dressing, and changing the dressing three times per week or as needed, were documented in the resident's record. Despite these recommendations, the treatment administration record showed that the NP's wound care orders were not implemented until more than two weeks after they were made. Interviews with the treatment nurse revealed a misunderstanding regarding whether to continue the previous treatment until supplies were exhausted, despite no such instruction being documented. The NP confirmed that the new wound care orders should have been started as soon as they were given, and the treatment nurse acknowledged that the recommended care was not initiated as ordered.