Failure to Follow Physician Orders During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency was identified when staff failed to follow physician orders during a pressure ulcer dressing change for a resident with multiple medical conditions, including a left femur fracture, heart failure, hypertension, renal insufficiency, neurogenic bladder, malnutrition, and respiratory failure. The resident was severely cognitively impaired and dependent on staff for transfers and toileting. Physician orders specified that the sacral pressure ulcer should be cleansed with normal saline, Silvadene applied, followed by a barrier cream, and then covered with an ABD pad twice daily. During an observed dressing change, the LPN did not cleanse the wound with normal saline as ordered. Instead, the LPN wiped off the old medication with a washcloth, applied Silvadene with the same gloved hands, then washed hands, donned new gloves, applied barrier cream, and covered the wound with an ABD pad. The LPN confirmed during interview that the wound was not cleansed with normal saline per physician orders, verifying that the prescribed protocol was not followed.