Failure to Follow Physician Orders for Wound Care and Catheter Management
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For one resident with a right heel arterial ulcer, the facility did not implement the wound consultant's recommendation to use a specific wound cleansing solution (Vashe) as ordered by the physician. Instead, a nurse used normal saline to cleanse the wound, despite the physician's order and wound care specialist's notes specifying the use of Vashe. The nurse acknowledged during an interview that the correct solution was not used and that normal saline does not have antibacterial properties, which was contrary to the wound care plan and facility policy. For another resident with a history of urinary retention and a Foley catheter, the facility failed to ensure that physician's orders were updated to reflect a change in catheter size following a urology consult. The resident returned from the consult with a different size catheter (18 Fr Coude) than what was documented in the physician's orders (16 Fr/10 ML). Nursing staff and the DON confirmed during interviews that the orders should have been updated to match the catheter size inserted during the consult, but this was not done. The discrepancy was identified during a review of the resident's medical record and direct observation of the catheter in place. Both deficiencies were identified through observation, record review, and staff interviews. The facility's policies required verification of physician's orders and adherence to specific procedures for wound care and catheter management, but these were not followed in the cases described. The failures involved not following wound care recommendations and not updating medical orders to reflect changes in treatment, as required by professional standards and facility policy.