Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
Nursing staff failed to follow physician orders for wound care for a resident with a history of osteomyelitis and two stage 4 pressure ulcers, one located on the right buttock and the other on the left hip. The facility's wound treatment management policy requires that wound treatments be provided in accordance with physician orders, specifying the cleansing method, type of dressing, and frequency of dressing change. Physician orders for this resident directed staff to cleanse both pressure ulcers with normal saline or wound cleanser, pat dry, apply wet to dry gauze with Dakin's solution at 1/4 strength, and secure with bordered gauze daily. During an observed wound care session, an LPN cleansed both wounds using Dakin's-soaked gauze, rather than following the prescribed method of cleansing with normal saline or wound cleanser and then patting dry before applying the Dakin's solution. The Assistant Director of Nursing confirmed that the wound care provided did not adhere to the physician's orders as required by facility policy.