Failure to Follow Wound Care Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident admitted with a sacral ulcer. Upon admission, the resident had a sacral ulcer that was unstageable with slough, and later identified as a Stage 4 pressure wound. The wound care team established a specific treatment plan, including the application of Leptospermum honey, alginate calcium, and a secondary gauze dressing, all to be applied once daily for 30 days. However, the Treatment Administration Record (TAR) for February and March documented a different treatment regimen, involving cleansing with normal saline solution (NSS) and application of mepilex with a cover dressing, which was signed off by nursing staff over several weeks. An interview with the Assistant Director of Nursing (ADON) and the RN unit manager confirmed that the nurses failed to relay the wound care team's orders and did not enter them into the computer system. As a result, the prescribed wound care treatments were not implemented as ordered by the wound care team, leading to a deficiency in the facility's pressure ulcer care for the resident.