Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for wound care for a resident with a stage 3 pressure ulcer on the right trochanter. The resident, who was severely cognitively impaired and diagnosed with dementia and anxiety, had a wound that required daily dressing changes with Medihoney as ordered by the physician. Documentation showed that the dressing was not changed as ordered, and the wound dressing observed was dated two days prior, with visible wound drainage through the gauze. The resident's care plan specified the need for daily treatment to promote healing and prevent infection, but this was not carried out as required. Interviews with facility staff revealed that the LPN assigned to the resident did not perform the wound care on the specified day, citing being too busy, and did not notify the DON or another nurse. The medical record inaccurately reflected that the resident refused the treatment, which was not corroborated by the LPN. The ADON confirmed the importance of daily Medihoney application for wound healing and acknowledged that the missed treatment could impede the healing process. The failure to provide the ordered wound care represented a missed opportunity to support healing and prevent infection for the resident.