Failure to Implement Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
A facility failed to follow pressure ulcer treatment recommendations for a resident who was cognitively impaired, required assistance for care needs, and had a diagnosis of atherosclerotic heart disease. Upon admission, the resident had an order to apply skin prep to the heels every shift. On July 17, a nurse documented a blood-filled blister on the resident's left heel, and a wound consult was ordered. The following day, the wound care consultant assessed the resident and recommended applying skin prep to the base of the wound and securing it with a bordered foam dressing. However, no new orders were obtained to reflect this recommendation. Review of the resident's treatment administration records showed that the bordered foam dressing was not applied to the left heel from July 18 through July 25, despite the consultant's recommendation. By July 25, the resident's left heel wound had progressed to a Stage 3 pressure ulcer. An interview with the Assistant Nursing Home Administrator confirmed that the wound care orders, including the foam dressing, were not added to the resident's wound orders, resulting in the recommended wound care not being completed.