Failure to Implement Updated Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a chronic stage 4 pressure ulcer received care and treatment in accordance with the wound consultant physician's orders. The resident, admitted with a stage 4 pressure ulcer on the ischium, had a care plan that included consultation and treatment by a wound physician, with specific orders for wound care. On multiple occasions, the wound consultant physician updated the treatment plan to include a collagen dressing in addition to antibacterial wound cleanser, Alginate, and foam dressing. However, review of the treatment administration records and physician's orders revealed that the updated order for the collagen dressing was not implemented in the electronic medical record or carried out by nursing staff. Interviews with nursing staff confirmed that the dressing changes performed did not include the collagen dressing as ordered by the wound consultant physician. The process for updating treatment orders after wound rounds was not followed, resulting in the resident not receiving the prescribed wound care. The deficiency was identified through review of medical records, treatment administration records, and staff interviews, which demonstrated a failure to implement and document the updated wound care orders for the resident's stage 4 pressure ulcer.