Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes mellitus type 2 and a below-the-knee amputation, who was assessed as having moderate cognitive impairment. The physician's order directed that the resident's left great toe be cleansed with normal saline, patted dry, Betadine applied every shift, and left open to air twice daily for wound care. Review of the Treatment Administration Record (TAR) for July 2025 showed no documentation of wound care for the left great toe as of mid-month. The resident confirmed that no treatment was being performed on the toe, and facility staff, including the ADON and DON, acknowledged that the wound care order had been entered incorrectly and the treatment was not being completed as ordered.