Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the formation and promote the healing of pressure injuries for one resident. Specifically, the resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, had physician orders for wound care to treat a stage 3 pressure injury on the right knee and a stage 4 pressure injury on the sacrococcyx. The care plan directed staff to follow these orders, which included cleansing with normal saline, application of collagen powder, Medihoney, calcium alginate, and zinc oxide, and covering with a dry dressing. During observation, the treatment nurse did not perform wound care on the resident's right knee as ordered and did not follow the physician's orders for the sacrococcyx wound. Instead of using normal saline, the nurse used Hibiclens to cleanse the wound and did not apply zinc oxide to the periwound area. The nurse confirmed these deviations during an interview. The Assistant Director of Nursing also acknowledged that following physician orders is essential and that using other products without an order is not acceptable. The facility's wound care policy required verification of physician orders for wound care procedures.