Failure to Provide Pressure Ulcer Care per Professional Standards and Physician Orders
Penalty
Summary
A resident with multiple medical conditions, including quadriplegia, morbid obesity, and type 2 diabetes, was readmitted to the facility with existing pressure ulcers. The resident's care plan and physician orders specified wound care protocols, including cleansing wounds with wound cleanser and applying specific dressings such as hydrofera blue for the right glute and wet-to-dry dressings for the left ischium if the wound vac was dislodged or malfunctioned. The facility's wound care policy and competency checklist also required wound cleansing and securing dressings as part of standard practice. On the observed date, an LVN performed wound care on the resident's left ischium and right glute. The LVN did not clean the inside of the wounds prior to applying dressings, only cleaning the peri-wound areas. Additionally, the LVN applied a wet-to-dry dressing to both wounds, contrary to the physician's order for the right glute, which required a hydrofera blue dressing. The LVN also failed to secure the dressings after application, leaving them unfastened. The LVN stated she followed instructions from the DNS and checked the orders, but misapplied the treatment and did not follow the facility's wound care policy or the specific physician orders. Interviews with the treatment nurse, ADNS, DNS, and NP confirmed that the expected standard of care was not met. All agreed that wounds should be cleansed prior to dressing application, dressings should be secured, and orders should be followed precisely. The facility's policy and competency checklist further supported these expectations, indicating that the LVN's actions were inconsistent with both professional standards and facility protocols.