Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
Staff failed to follow physician orders for the treatment of a facility-acquired pressure ulcer for one resident with severe cognitive impairment. The resident had a new right achilles (heel) pressure ulcer, and physician orders directed staff to cleanse the wound with normal saline, apply skin prep to the necrotic area, and cover with a foam dressing every day shift on Monday, Wednesday, and Friday, as well as as needed for saturation or dislodgment. Observations revealed that the foam dressing was partially hanging off and exposing the wound on multiple occasions, with photographic evidence obtained. The dressing was also noted to be dated several days prior, indicating it had not been changed as ordered. Review of the Treatment Administration Record (TAR) showed that an LPN had signed off on performing the wound care treatment on specific dates, but direct observation contradicted these records. The resident was observed experiencing discomfort and was found with a foul-smelling dressing with dark brownish drainage and eschar present. The dressing was removed by staff only after the resident indicated discomfort, and it was confirmed that the dressing had not been changed according to the physician's orders.