Failure to Follow Wound Care Plan Interventions for Two Residents
Penalty
Summary
Facility staff failed to implement care plan interventions during wound care for two residents with pressure ulcers. For one resident, physician's orders and the care plan required cleansing and patting dry an excoriated area on the right hip and a stage 3 pressure ulcer on the sacrum before applying specific wound treatments and dressings. During observed wound care, the LPN did not pat either wound dry before applying the prescribed ointments, powders, and dressings, contrary to both the physician's orders and the care plan. The resident had a history of pressure ulcers and was severely cognitively impaired at the time of the incident. For the second resident, who also had a history of pressure ulcers and severe cognitive impairment, the care plan and physician's orders required cleansing and patting dry a stage 2 sacral pressure wound before applying calcium alginate and a foam dressing. During observed wound care, the LPN cleansed the wound but did not pat it dry before applying the dressing. The LPN acknowledged not following the care plan or physician's orders during interviews, and both the DON and RN confirmed that the care plan was not followed during these wound care procedures.