Failure to Follow Physician Orders for Wound Care
Penalty
Summary
Staff failed to follow physician orders for wound care for one resident with diagnoses including high blood pressure, diabetes, and heart failure. The physician's order required daily cleansing of both lower extremities with Vashe wound cleanser, a 3-5 minute soak, application of silver wound gel to the wound bed, covering with mepitel, an ABD pad, and wrapping with kerlix and ace wrap. Observations revealed that the resident's dressings were not changed daily as ordered, and ace wraps were not consistently applied. The resident reported that dressings were changed only three to four times in the previous week and that ace wraps had only been applied once during a hospital stay. Direct observation of wound care by an LPN showed that the wounds were cleaned with Vashe, but no soak was performed, silver wound gel and mepitel were not applied, and ace wraps were omitted. Instead, silver sulfadiazine cream was used, which is not the same as silver wound gel per staff interview. The treatment cart did not contain silver wound gel. The Administrator confirmed that staff are expected to follow physician orders and facility policies.