Failure to Perform Wound Care as Ordered by Physician
Penalty
Summary
A deficiency occurred when a resident's wound treatment was not performed as ordered by the physician. The resident, who had multiple diagnoses including hypertension, heart arrhythmias, heart failure with a pacemaker, hypothyroidism, osteoarthritis, atherosclerotic heart disease, and high cholesterol, had a skin tear on the left shin. The physician's order specified that the wound should be cleansed with normal saline, xeroform applied, and covered with border gauze every night shift on Tuesday, Thursday, and Saturday. Observation revealed that the wound dressing had not been changed as ordered, with the last documented treatment occurring two days prior to the scheduled change. The LPN confirmed that the wound treatment was not completed according to the physician's instructions. Review of facility policy indicated that wound treatments were to be provided in accordance with physician orders, including the specified cleansing method, dressing type, and frequency.