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F0684
D

Failure to Follow Physician's Orders for Wound Care

Dubois, Pennsylvania Survey Completed on 09-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow physician's orders for wound care for one resident. According to facility policy, licensed nurses are required to complete physician orders as written, including timing and frequency. A resident with severe cognitive impairment and a diagnosis of dementia was found to have a large skin tear on the right forearm, which was assessed by a registered nurse. The physician ordered daily wound care, including cleansing, application of xeroform, and covering with a foam dressing. Review of the Treatment Administration Record showed that the dressing changes were not completed as ordered on multiple dates. The Director of Nursing confirmed that the dressing changes were missed on the specified dates.

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