Failure to Maintain Physician-Ordered Dressing on Sacral Pressure Ulcer
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for a resident with a stage 4 sacral pressure ulcer. The resident, who had a history of sepsis, osteomyelitis of the sacrum and coccyx, and a recent skin graft to the sacrococcyx area, was admitted and readmitted with significant medical needs. Physician orders and the resident's care plan required the application of Silvadene and Santyl ointments, cleansing with normal saline, and the use of a foam dressing to the sacral wound. However, during wound care observation, the resident's sacral pressure injury was found without a dressing in place. Staff interviews confirmed that the dressing was not present during morning care and that CNAs were instructed not to remove dressings, with responsibility for replacement falling to the charge nurse or RN supervisor if a dressing became soiled or detached. Record reviews further indicated that the facility's policies and the treatment nurse's job description required adherence to prescribed wound care treatments to prevent infection and promote healing. Despite these protocols, the resident's wound was left uncovered, contrary to both physician orders and facility policy. The DON and treatment nurses acknowledged that the wound should always be covered to prevent infection and further injury, and that the absence of a dressing was not in accordance with established procedures.