Failure to Follow Wound Care Orders and Policy for Pressure Ulcer Management
Penalty
Summary
Facility staff failed to follow provider orders and the facility's Skin Integrity and Wound Management policy for a resident with multiple wounds. The resident was admitted with a right heel that was pink and boggy and an open wound on the dorsal right foot. Provider orders directed staff to apply skin prep to both heels, ensure heels were offloaded, monitor skin integrity every shift, and perform specific wound care to the right dorsal/lateral foot. Despite these orders, documentation showed that nursing staff did not consistently monitor or describe the wounds as required, and weekly skin checks lacked adequate detail about the resident's wounds. A wound care consult later provided new daily care orders for three wounds, including cleansing with wound cleanser, applying Betadine, and leaving the wounds open to air. However, review of the Treatment Administration Records revealed that nursing staff did not initiate these new orders and continued with the previous wound care regimen. The resident was subsequently sent to the emergency room after being found with pressure sores on the heels, reportedly due to not being moved by staff. Nursing documentation did not reflect changes in the resident's wound condition, and daily monitoring as required by policy was not evident.