Failure to Provide Wound Care per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide wound care in accordance with physician orders and facility policy for one resident with a non-pressure ulcer. The resident had a physician order for wound care to be performed every three days, including cleaning the wound with normal saline, applying Mupirocin ointment, and covering with Mepilex. Documentation showed that wound care was completed on one scheduled date but was not documented or performed on the next scheduled date, as evidenced by the absence of staff initials in the treatment record. The resident reported that the wound care was not performed as ordered and that the wound was not irrigated as specified in the physician's instructions. Interviews with staff revealed a lack of awareness and adherence to the wound care schedule. The LPN/unit manager stated that a PRN order had been obtained and that she provided the dressing change a day after it was missed, but the dressing was not signed, dated, or timed as required. Another LPN was unaware of why the wound care was missed, and the DON and Administrator acknowledged that the care had not been completed as ordered. The resident had a history of diabetes, a non-pressure chronic ulcer, and vascular dementia, with intact cognition at the time of the incident.