Failure to Maintain and Follow Current Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care were completed, current, and followed by nursing staff for two residents. For one resident with a left heel deep tissue injury, there was no physician order in place for a period of several days, and staff were unable to explain the absence of the order. During this time, the resident's stable eschar was left open to air, and offloading with pillow boots continued, but the lack of a documented order meant that care was not guided by current physician instructions. For another resident with bilateral below-the-knee amputation surgical incisions, the physician order for dressing changes was found to be vague and required clarification. Staff used various dressings, including ace wraps, which were later determined to be inappropriate for the surgical incisions. The physician's specific recommendations for wound care were documented in a progress note but were not reflected in the active orders until several days later, resulting in dressing changes that did not align with the intended treatment plan.