Failure to Follow Physician Orders for Wound and Catheter Care
Penalty
Summary
Staff failed to follow physician orders for two residents, resulting in missed and undocumented treatments for wounds, intravenous (IV) sites, and indwelling catheters. For one resident with osteomyelitis, multiple sclerosis, and a stage 4 pressure ulcer, physician orders required weekly skin checks, specific wound care, regular PICC line dressing changes, and routine catheter care. Documentation revealed that several ordered dressing changes and skin checks were not completed or recorded, and catheter care and anchor changes were not included on the treatment records for staff to document. Observations confirmed that the PICC line dressing was overdue for change, the wound dressing was soiled and not changed as ordered, and there was no anchor securing the urinary catheter. Another resident with a history of urinary tract infection, urinary retention, and chronic kidney disease also had physician orders for weekly skin assessments, catheter care every shift, and regular anchor changes. Observations showed the resident's catheter tubing was touching the floor, there was visible sediment in the tubing, and no anchor was securing the catheter to the leg. The resident reported not receiving catheter care for several days, and staff confirmed that the catheter tubing should not be on the floor and that the anchor was missing. Interviews with nursing staff and the Director of Nursing confirmed that staff did not follow physician orders for wound and catheter care, and that required documentation was missing from the treatment records. The facility was unable to provide a policy for following physician orders when requested, and the observed failures were not in accordance with the facility's own wound treatment and skin assessment policies.