Failure to Follow Prescribed Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to follow prescribed treatment orders for pressure wounds in two residents. In one case, a wound care nurse and aide changed a resident's sacral wound dressing and did not apply the ordered collagen and calcium alginate dressings, instead using only a white bordered gauze dressing. The nurse was unsure why the prescribed treatment was not followed, despite clear orders and care plans specifying the use of collagen and calcium alginate with a bordered gauze dressing. The resident's wound was present on admission, classified as stage 4, and exhibited slough tissue and undermining. In another case, a resident developed a facility-acquired unstageable pressure injury to the right heel. The wound care nurse applied a dressing that included medihoney ointment and adaptic, but did not follow the specific order to use medihoney with calcium alginate, ABD pad, and rolled gauze. The treatment administration record did not show that the nurse practitioner's order was implemented. The wound care nurse stated she believed she was following the correct order, and indicated that the wound care team was responsible for reviewing and transcribing treatment orders. Facility policy required prompt identification and appropriate treatment for skin breakdown, but the prescribed wound care protocols were not followed in these cases.