Failure to Follow Wound Care Orders for Sacral Pressure Ulcer
Penalty
Summary
A resident with a Stage 4 pressure ulcer on the sacrum, measuring 1.2 x 0.8 x 0.2 cm with moderate serous drainage, had a physician's order for daily wound care. The order specified cleansing the wound with normal saline, applying nickel-thick Santyl ointment, and covering with a dry dressing. Review of clinical records showed that the wound treatment was not performed on one of the ordered days, and on another day, the wound was observed without a dressing and with a large bowel movement present when the resident's incontinence brief was opened. During staff interviews, the nurse assigned to the resident admitted to documenting that the wound care had been completed for the day, despite not having performed the treatment. The Director of Nursing was unable to provide an explanation for the missed treatment. The facility failed to follow the physician's wound care orders for the resident's sacral pressure ulcer as required.