Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with physician orders and standards of clinical practice for two residents. For one resident with a left above-the-knee amputation and additional wounds on the right foot, the wound care nurse did not follow the physician's order for wound dressing. Specifically, the nurse used an ACE wrap instead of the ordered kerlix to secure the dressing on the right foot. The resident's care plan included interventions to follow facility protocols for impaired skin integrity, but these were not adhered to during observed wound care. For another resident with a history of a gunshot wound, paralysis, and an unstageable sacral pressure ulcer, the wound care nurse also failed to follow the physician's wound care order. The nurse did not secure the sacrococcyx wound with border gauze as ordered, instead applying only Maxorb AG and ABD dressing. Both incidents were observed directly, and the wound care nurse acknowledged not following the physician's orders when questioned. The facility's policy requires treatments to be rendered in accordance with specific physician orders, which was not done in these cases.