Failure to Implement Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards of practice for a resident with a Stage IV pressure ulcer. The resident, who was cognitively intact, had a documented history of a pressure ulcer on the left lateral malleolus, with wound clinic notes specifying changes in wound care treatment. On two separate occasions, the wound clinic recommended discontinuing the previous treatment of collagen powder mixed with bacitracin and instead applying a collagen sheet and Hydrogel to the wound base, including areas of undermining, every other day and as needed. Despite these recommendations, a review of the resident's Treatment Administration Record for the relevant month showed that the resident continued to receive the previous treatment and did not receive the Hydrogel as advised by the wound clinic. The DON confirmed that the updated wound care recommendations from the wound consultant were not followed. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) for failing to ensure that wound consultant recommendations were reviewed with the attending physician and implemented as directed.