Failure to Update and Implement Physician-Recommended Wound Care Orders
Penalty
Summary
A deficiency was identified when a resident with two Stage 4 pressure ulcers, one on the right hip and one in the sacral area, did not receive updated wound care treatment as recommended by the in-house wound consult physician. The physician's recommendations, made after a debridement procedure, included specific instructions for cleansing and dressing both wounds using Dakin solution, santyl with calcium alginate, and appropriate dressings. However, these recommendations were not incorporated into the resident's treatment orders. Instead, the resident continued to receive wound care based on outdated orders from several weeks prior, which did not reflect the physician's updated recommendations. Documentation showed that the older orders were followed for an extended period, and the Director of Nursing confirmed that the process for updating orders after wound consultations was not followed in this instance. The failure to update and implement the recommended wound care regimen resulted in the resident not receiving treatment intended to promote healing of the pressure ulcers.