Failure to Implement Physician-Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident with a Stage IV sacral pressure injury received appropriate and adequate wound care as ordered by the physician upon admission. The hospital discharge summary specified daily application of Collagenase ointment for the wound, but this order was not transcribed or implemented by nursing staff. Instead, the resident received only normal saline wash and a dry protective dressing (DPD) for several days following admission. Nursing staff did not reference the hospital discharge summary when obtaining wound care orders, and the physician assumed the hospital's wound care orders were being followed. The Director of Nursing confirmed that the facility's protocol was to follow hospital discharge wound care orders until the wound nurse practitioner could assess the resident, but this did not occur. The resident had significant medical conditions, including end stage renal disease requiring dialysis, diabetes mellitus, and a Stage IV sacral pressure injury. Documentation showed that the wound was present and measured upon admission, but the prescribed treatment was not provided. The failure to implement the correct wound care orders resulted from a lack of communication and adherence to protocol by nursing staff, as well as an assumption by the physician that the appropriate care was being given.