Failure to Provide Wound Care per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including a sacral wound, was not provided wound care in accordance with physician orders. The resident's care plan and physician orders specified that the dressing to the sacral wound should be changed daily and as needed, with specific wound care procedures to be followed. However, during an observation, it was noted that the dressing on the resident's buttocks was dated two days prior, indicating that the dressing had not been changed daily as ordered. The Treatment Administration Record for the month showed all treatments as completed, but direct observation and staff interview confirmed that the dressing had not been changed according to the prescribed schedule. The resident was highly dependent on staff for all activities of daily living and had severely impaired cognition, requiring substantial assistance for mobility and hygiene. The failure to change the dressing daily as ordered was confirmed by both observation and interview with the LPN who performed the wound care. This lapse in following physician orders for wound care constituted a deficiency in the facility's pressure ulcer care practices for this resident.