Failure to Follow Physician Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for a resident with a Stage 4 pressure ulcer on the left buttock. The resident, who was dependent on staff for all activities of daily living due to anoxic brain injury and functional quadriplegia, had physician orders specifying that the wound should be cleansed with normal saline, Medi Honey applied to the wound bed, and barrier cream to the peri-wound area daily. However, during an observation, the treatment nurse was seen applying Santyl ointment instead of Medi Honey as ordered. The nurse admitted to using Santyl based on previous experience rather than current physician orders and acknowledged that the correct treatment should have been verified prior to administration. Record reviews confirmed that the physician's orders and the treatment administration record both specified Medi Honey for the wound care regimen. The facility's policy required staff to verify the five rights of medication administration before providing care, which was not followed in this instance. Interviews with the treatment nurse and the Director of Nursing confirmed that the deviation from the prescribed treatment could directly impact the resident's well-being and healing process. The deficiency was identified through observation, interview, and record review, and was limited to this resident.