Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatments and services consistent with professional standards of practice during wound care for a resident with multiple pressure ulcers and wounds. The resident, who had severe cognitive impairment and required extensive to total assistance with activities of daily living, had a medical history including type 2 diabetes mellitus, cellulitis, and pressure-induced deep tissue injuries (DTIs) on both heels. Physician orders were in place for specific wound care treatments for the resident's left heel, right heel, right medial second toe, and right third toe tip, including the use of topical Lidocaine, normal saline cleansing, skin prep, Hydrofera Blue, and foam dressings, with instructions to reassess and notify the physician if changes occurred. During an observed wound care session, the nurse did not follow the physician's orders as written. The nurse applied Lidocaine only to the right second toe, despite orders to use it on all wounds, and did not address the wound on the right third toe at all. Additionally, the nurse placed a single foam dressing over all the toes on the right foot, which was not in accordance with the specific wound care orders and could result in the toes being pressed together. The nurse also admitted to not verifying the physician's orders prior to gathering supplies and acknowledged not following the orders exactly as written. Interviews with facility leadership confirmed that the nurse's actions did not align with facility policy or physician orders. The Director of Nursing and the Administrator both stated that the expectation was for nurses to verify and follow physician orders precisely and to prepare supplies accordingly. The failure to follow wound care orders and policies was identified as a deficiency during the survey.