Failure to Provide Pressure Ulcer Care per Physician Orders and Accurate Transcription
Penalty
Summary
A deficiency was identified in the care of a resident with a stage 3 sacral pressure ulcer, who also had diagnoses of muscle weakness and osteomyelitis. The resident required substantial to maximal assistance for activities such as dressing, toileting, and repositioning in bed. The care plan specified that wound treatments should be administered as ordered and in accordance with facility protocols. However, during an observed wound treatment, an LPN failed to follow proper hand hygiene protocols and attempted to use a collagen matrix dressing instead of the physician-ordered calcium alginate with silver dressing. The LPN incorrectly believed the two dressings were interchangeable, but the Infection Prevention Nurse clarified that they were not, and the correct dressing was subsequently applied after intervention. Additionally, a review of the resident's wound care orders revealed that the frequency of dressing changes was incorrectly transcribed. The wound APRN had recommended dressing changes twice daily, but the order was entered as once daily. This transcription error was confirmed by the Infection Prevention Nurse, who was responsible for transcribing the recommendations. The facility's policies required that physician orders be complete and accurate, and that treatments be performed as ordered, but these requirements were not met in this instance.