Failure to Provide Physician-Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to provide wound care treatment as ordered by the physician for one resident with a pressure injury related to a medical device. The resident, who had chronic kidney disease, a urinary tract infection, and a pressure ulcer, was admitted with an indwelling Foley catheter. Physician orders required daily wound care for an open wound on the penis, including cleansing with normal saline, applying hydro gel, and covering with a dry dressing. During observation, it was found that the wound was not covered with a dressing as ordered, and both the Licensed Vocational Nurse and Treatment Nurse confirmed that the wound should have been covered at all times according to the physician's orders. Further interviews revealed that the Certified Nursing Assistant assigned to the resident had changed the resident's diaper earlier in the day and also noted that there was no bandage over the open sore at that time. The facility's policy required treatments to pressure injuries and other skin integrity problems to be provided as ordered by the physician. The failure to keep the wound covered as ordered constituted a deficiency in following physician orders for wound care treatment.