Failure to Follow Wound Vac Orders for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to follow a physician's order for wound care for a resident admitted with a Stage 4 pressure ulcer to the sacrum, who also had osteomyelitis and was receiving IV antibiotics. The physician's order required the use of a wound vac on a continuous setting, with placement and function to be checked every shift and the canister changed as needed. Observations revealed that the wound vac machine was off and not functioning for several hours, with the canister filled and the device unplugged from the adaptor. Documentation did not show that the wound vac was monitored during this period. Interviews with nursing staff indicated a lack of awareness regarding the wound vac's status, with one nurse stating they had not checked the device all day and only discovered it was not connected when prompted. Another nurse reported having observed the wound vac working earlier and documented it as such, but there was no evidence of monitoring between the observed times. The clinical records did not reflect consistent monitoring or adherence to the physician's order for continuous wound vac therapy.