Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
A resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, vascular dementia, and muscle wasting, developed a Stage 2 pressure ulcer on the right heel. Physician orders were in place to cleanse the wound, apply calcium alginate, and cover it with ABD and rolled gauze daily. However, documentation and interviews revealed that the dressing was not changed as ordered on two consecutive days. The treatment administration record showed that staff had signed off on the dressing changes, but the dressing remained unchanged and was still dated from two days prior. This discrepancy was brought to staff attention by the resident's family, who noticed the outdated dressing. Further investigation confirmed that the responsible LPN had not performed the dressing changes on the specified dates and had mistakenly documented completion in the electronic charting system. Facility policy required that residents with impaired skin integrity receive necessary treatment and services to promote healing, and that neglect, defined as failure to provide necessary services to avoid physical harm, be prevented. The facility was unable to provide a specific policy regarding pressure wound care upon request.