Failure to Follow Wound Care Provider Recommendations for Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate wound care for a resident with a Stage 3 pressure ulcer in the sacral area. The wound care provider made specific recommendations for wound treatment, including the use of Collagen and later Dakins solution with fluffed gauze, zinc oxide paste, and transparent film, to be applied twice daily. However, these recommendations were not entered into the resident's treatment orders or the Treatment Administration Record (TAR). Instead, the facility ordered a different treatment regimen, including cleansing with normal saline instead of Dakins solution and applying the treatment only once daily on certain days, which did not match the wound care provider's instructions. Further review revealed that wound care was not documented as completed for several days, and when it was documented, it was not done according to the recommended frequency. Interviews with the DON and the Unit Manager confirmed that the wound care provider's recommendations were not followed and that the orders in the TAR differed from those recommendations. The resident's wound worsened from Stage 3 to Stage 4, and the wound care provider ultimately recommended hospital transfer for further management.