Failure to Timely Implement Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident received timely and appropriate wound care services as recommended by the wound care provider. The resident, who had a history of cerebral infarction, hemiplegia, and incontinence, was identified as being at risk for pressure injuries. After a partial thickness sacral wound was resolved, the wound care provider recommended the continued use of Triad paste twice daily for skin protection. However, a review of the clinical record revealed that there was no active physician order for the barrier cream as recommended, and staff interviews confirmed that the order had not been implemented. Further, staff noted that the resident's buttock was excoriated and the resident reported discomfort, indicating ongoing skin issues. The wound care nurse practitioner stated that wound care recommendations should be implemented the next day if supplies are available, or the provider should be notified if not. The Director of Nursing confirmed that the facility did not ensure timely implementation of wound care recommendations for the resident, resulting in a failure to provide necessary services as required by facility policy and state regulations.