Failure to Follow Physician Orders for Pressure Ulcer Wound Care
Penalty
Summary
The facility failed to ensure physician orders for pressure ulcer wound care were followed for three residents with documented pressure ulcers. Each resident had specific wound care orders, including cleansing, application of wound care products, and dressing changes at prescribed intervals. However, treatment administration records showed multiple dates where there was no documentation that the required dressing changes were completed for various wounds, including stage III and IV pressure ulcers on the sacrum, heel, gluteal area, ischial tuberosity, and elbow. Residents involved had significant medical histories, such as paraplegia, protein-calorie malnutrition, adult failure to thrive, muscle weakness, and type 2 diabetes mellitus. Their care plans and provider orders detailed the necessary wound care interventions, but the records indicated repeated lapses in performing or documenting these treatments. Interviews with the residents confirmed that there were several occasions when their dressings were not changed as ordered, though they could not specify exact dates or reasons. Staff interviews revealed that LPNs and the infection preventionist acknowledged there were times when dressing changes were not completed and that these instances were reported to the DON. Staff consistently stated that if a dressing change was not documented, it was not done. The interim DON confirmed that staff were expected to follow provider orders for wound care. The facility's wound treatment management policy required treatments to be completed according to physician orders, but this was not consistently followed.