Failure to Update and Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to provide pressure wound treatment according to the physician's updated orders for one resident with a stage 3 pressure ulcer. The resident, who had diagnoses including chronic kidney disease, polyneuropathy, and peripheral vascular disease, was admitted with a stage 3 pressure injury to the right buttock/ischium. The initial physician's order directed daily wound care with wound cleanser, barrier wipe, calcium alginate, and bordered gauze. However, a new order was issued by the wound care nurse practitioner to change the treatment to cleansing, application of collagen, and covering with bordered gauze three times per week and as needed. Despite the updated order, the Treatment Administration Record (TAR) and Physician Order Sheet (POS) were not updated to reflect the new treatment regimen. Nursing staff continued to provide the previous daily treatment, as observed during wound care, and the documentation showed the outdated treatment was administered. The Director of Nursing acknowledged that the new order had not been entered into the medical record, resulting in the resident not receiving wound care as per the most recent physician's instructions.