Failure to Provide Post-Operative Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide post-operative wound care according to physician orders for one resident who was admitted with a displaced intertrochanteric fracture of the right femur and severe protein-calorie malnutrition. Physician orders specified a wound care regimen that included cleaning the right hip with hibiclens on day 5 post-operation, removing the aquacel dressing and cleaning the surgical site with hibiclens and 4 by 4s on day 10 post-operation, and removing staples and applying steri strips for two weeks. Review of the resident's Treatment Administration Record (TAR) for May 2025 showed no documentation that these orders were followed as directed. During an interview, the Director of Nursing confirmed that the expectation is for all physician orders to be followed or for the physician to be notified if orders are not carried out. The Director also acknowledged that the resident's staples should have been removed on the specified date according to the orders. Facility policy requires wound care procedures and treatments to be performed according to physician orders and for the physician to be contacted for order changes or to notify of changes in skin condition or refusals of care.