Failure to Follow Physician-Ordered Wound Care Treatments
Penalty
Summary
Staff failed to provide physician-ordered wound care treatments for a resident with multiple wounds, including a stage three pressure ulcer and other sores on the thighs, abdominal fold, buttocks, and back. The resident had a complex medical history, including bullous pemphigoid, morbid obesity, lymphedema, and other chronic conditions. Physician orders specified the use of particular wound care products and dressings, such as betadine, calcium alginate, silicone super absorbent dressings, and foam dressings, to be applied to specific wound sites following cleansing with normal saline. During an observed wound care procedure, an LPN did not follow the physician's orders and instead used calcium alginate with silver and covered all wounds with abdominal pads and gauze, securing them with paper tape. The LPN stated that the required silicone super absorbent and foam dressings were not available in the facility, leading to the substitution of materials. The facility's policy required staff to follow physician orders and manufacturer guidelines for wound care products, but these were not adhered to during the observed treatment.